A pregnant woman has been receiving a magnesium sulfate infusion for the treatment of severe preeclampsia for 24 hours.
On assessment, the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus.
The patient complains, “I’m so thirsty and warm.” The nurse:
Calls for a stat magnesium sulfate level
Administers oxygen
Discontinues the magnesium sulfate infusion
Prepares to administer hydralazine
The Correct Answer is C
The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing.
Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely.
The nurse should stop the infusion immediately and notify the provider.
Choice A is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity.
The nurse should act quickly to prevent further complications.
Choice B is wrong because administering oxygen will not reverse the effects of magnesium toxicity.
Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.
Choice D is wrong because hydralazine is an antihypertensive medication that lowers blood pressure.
The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg).
Hydralazine may cause hypotension and fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Visible peristalsis and weight loss. These are symptoms of pyloric stenosis, which is a thickening or narrowing of the pylorus, a muscle in the stomach that blocks food from entering the small intestine. Babies with pyloric stenosis often have forceful vomiting, which may cause dehydration.
Choice A is wrong because abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis.
They may indicate other conditions such as appendicitis or bowel obstruction.
Choice B is wrong because a rounded abdomen and hypoactive bowel sounds are also not specific for pyloric stenosis.
They may be seen in other causes of vomiting or abdominal distension.
Choice D is wrong because distention of the lower abdomen and constipation are not related to pyloric stenosis.
They may be due to other problems such as Hirschsprung’s disease or intestinal atresia. Normal ranges for weight gain in infants depend on their age, sex, and feeding method. Generally, infants should gain about 25 to 35 grams per day in the first 3 months of life.
Correct Answer is B
Explanation
Measles (rubeola) is a communicable disease that is characterized by Koplik’s spots, which are clustered, white lesions on the buccal mucosa opposite the lower molars. They appear two to three days before the measles rash and are pathognomonic for measles.
Choice A is wrong because rubella is a different viral infection that causes a mild rash and fever, but does not have Koplik’s spots.
Choice C is wrong because chickenpox (varicella) is caused by the varicella-zoster virus and produces fluid-filled blisters on the skin, not white spots in the mouth.
Choice D is wrong because exanthema subitum (roseola) is caused by the human herpesvirus 6 or 7 and causes a high fever followed by a pink rash on the trunk and neck, but no oral lesions.
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