A woman is being treated for preterm labor with magnesium sulfate. Which finding by the nurse indicates magnesium sulfate toxicity?
Select one:
Respiratory rate of 16.
Complaints by the client of feeling flushed and warm.
Fetal heart rate of 120.
Patellar reflexes are absent.
The Correct Answer is D
Choice A Reason: Respiratory rate of 16. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Respiratory rate is a measure of the number of breaths per minute, which reflects the respiratory function and oxygenation status. Respiratory rate of 16 is within the normal range for adults, which is 12 to 20 breaths per minute. Respiratory rate of 16 does not indicate magnesium sulfate toxicity, which can cause respiratory rate below 12 breaths per minute.
Choice B Reason: Complaints by the client of feeling flushed and warm. This is an incorrect answer that indicates a common side effect that does not indicate magnesium sulfate toxicity. Feeling flushed and warm are sensations that are caused by vasodilation (widening of blood vessels), which can occur as a result of magnesium sulfate administration. Feeling flushed and warm are not signs of magnesium sulfate toxicity, but rather expected and mild reactions that usually subside within a few hours.
Choice C Reason: Fetal heart rate of 120. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Fetal heart rate is a measure of the number of beats per minute of the fetal heart, which reflects the fetal well-being and oxygenation status. Fetal heart rate of 120 is within the normal range for fetuses, which is 110 to 160 beats per minute. Fetal heart rate of 120 does not indicate magnesium sulfate toxicity, which can cause fetal heart rate below 110 beats per minute or above 160 beats per minute.
Choice D Reason: Patellar reflexes are absent. This is because absent patellar reflexes are a sign of magnesium sulfate toxicity, which is a condition where the level of magnesium in the blood is too high, which can cause adverse effects on the neuromuscular and cardiovascular systems. Magnesium sulfate is a medication that is used to prevent or treat preterm labor, which is labor that occurs before 37 weeks of gestation. Magnesium sulfate works by relaxing the uterine muscles and inhibiting uterine contractions. However, magnesium sulfate can also affect other muscles and nerves in the body, and cause symptoms such as muscle weakness, respiratory depression, hypotension, or cardiac arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.
Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic fluid, which can be cleared by suctioning or burping.
Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.
Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not affect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.
Correct Answer is B
Explanation
Choice A Reason: A fetal heart rate baseline of 140 with one acceleration to 155 for 15 seconds within 30 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. A non-reactive NST may suggest fetal hypoxia, distress, or sleep, but it does not necessarily indicate a problem. A non-reactive NST may require further testing or stimulation to elicit a reactive result.
Choice B Reason A fetal heart rate baseline of 140 with two accelerations to 160 for 15 seconds within 20 minutes. This is because this strip meets the criteria for a reactive NST, which is a non-invasive test that evaluates fetal well- being and oxygenation by measuring the fetal heart rate response to fetal movements. A reactive NST is defined as having at least two accelerations of the fetal heart rate that are at least 15 beats per minute above the baseline and last for at least 15 seconds within a 20-minute period.
Choice C Reason: A fetal heart rate baseline of 130 with two accelerations to 135 for 15 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in amplitude, as they are only 5 beats per minute above the baseline, instead of at least 15 beats per minute.
Choice D Reason: A fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes. This is an incorrect answer that indicates a non-reactive NST, which is a test that does not meet the criteria for a reactive NST. The accelerations in this strip are not sufficient in duration, as they last only for 10 seconds, instead of at least 15 seconds.
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