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 D
Explanation
This test measures the amount of chloride in the sweat, which is abnormally high in people with cystic fibrosis (CF). CF is an inherited disorder that affects the cells that produce mucus, sweat, and digestive juices.
Choice A is wrong because bronchoscopy is a procedure that allows the doctor to examine the airways and lungs, but it is not essential for diagnosing CF.
Choice B is wrong because serum calcium is a blood test that measures the level of calcium in the blood, which is not related to CF.
Choice C is wrong because urine creatinine is a test that measures the amount of creatinine in the urine, which reflects the kidney function, but it is not relevant to CF.
Normal ranges for sweat chloride test are:
- Less than 40 millimoles per liter (mmol/L) for children and adults
- Less than 30 mmol/L for infants younger than 6 months
A sweat chloride level of more than 60 mmol/L is considered positive for CF.
Correct Answer is D
Explanation
This is because toddlers continue to have the short, straight internal ear canal of infants.
The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose the toddler to frequent infections.
Choice A is wrong because respirations are abdominal. This does not affect the susceptibility to infection.
Choice B is wrong because pulse and respiratory rates are slower than those in infancy. This also does not affect the susceptibility to infection.
Choice C is wrong because defense mechanisms are less efficient than those during
infancy. This is not true, as the defense mechanisms are more efficient compared with those of infancy.
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