A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?

Choice A Reason:

While assessing bowel sounds is important for overall patient care, it is not the priority when administering magnesium sulfate. Magnesium sulfate is primarily used to prevent seizures in preeclampsia and to manage preterm labor. Its side effects can include respiratory depression, making respiratory rate the most critical assessment.

Choice B Reason:

Respiratory rate is the priority assessment when administering magnesium sulfate. Magnesium sulfate can cause respiratory depression, which can be life-threatening. Monitoring the respiratory rate helps ensure that the client is not experiencing adverse effects from the medication. The normal respiratory rate for adults is 12-20 breaths per minute.

Choice C Reason:

Temperature monitoring is important for detecting infections and other conditions, but it is not the priority in this context. Magnesium sulfate does not typically affect body temperature, so this assessment is less critical compared to respiratory rate.

Choice D Reason:

Fetal heart rate (FHR) monitoring is crucial for assessing fetal well-being, especially in clients with preeclampsia or preterm labor. However, the immediate priority when administering magnesium sulfate is to monitor the mother’s respiratory rate to prevent respiratory depression.

Choice A Reason:

Using the intercostal space as a landmark for measuring chest circumference is not standard practice. The intercostal spaces are the spaces between the ribs, and using them as a reference point can lead to inconsistent measurements due to variations in rib spacing and positioning.

Choice B Reason:

The xiphoid process is the lower part of the sternum. While it is a significant anatomical landmark, it is not used for measuring chest circumference in newborns. The xiphoid process is located too low on the chest to provide an accurate and consistent measurement of chest circumference.

Choice C Reason:

The sternal notch, also known as the jugular notch, is the upper part of the sternum. Similar to the xiphoid process, it is not used for measuring chest circumference in newborns. The sternal notch is located too high on the chest and does not provide a consistent reference point for chest circumference measurements.

Choice D Reason:

The nipple line is the correct anatomical landmark for measuring the chest circumference of a newborn. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards.