A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
a sleepy, sedated affect.
absent ankle clonus.
a respiratory rate of 10 breaths/min.
deep tendon reflexes of 2+.
The Correct Answer is C
Choice A reason: A sleepy, sedated affect is not a concerning sign, as it is a common side effect of magnesium sulfate. Magnesium sulfate is a central nervous system depressant that can cause drowsiness, lethargy, and reduced alertness.
Choice B reason: Absent ankle clonus is not a concerning sign, as it indicates a normal neuromuscular response. Ankle clonus is a rhythmic jerking of the foot when the ankle is dorsiflexed. It is a sign of hyperreflexia, which can occur in severe preeclampsia due to increased blood pressure and cerebral edema.
Choice C reason: A respiratory rate of 10 breaths/min is a concerning sign, as it indicates respiratory depression. This is a serious complication of magnesium sulfate toxicity, which can lead to respiratory arrest and death. The nurse should monitor the woman's respiratory rate closely and report any signs of respiratory distress.
Choice D reason: Deep tendon reflexes of 2+ are not a concerning sign, as they indicate a normal neuromuscular response. Deep tendon reflexes are graded from 0 to 4, with 2 being the average. Magnesium sulfate can cause hyporeflexia or areflexia, which are signs of magnesium sulfate toxicity.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The NST has no known contraindications, as it is a non-invasive and safe test that does not stimulate uterine contractions or cause fetal distress. It is the most widely used method of antepartum fetal surveillance.
Choice B reason: The NST is not slightly more expensive than the CST, as it requires less time and equipment. The NST usually takes 20 to 40 minutes, while the CST may take up to 2 hours. The NST only needs a fetal monitor, while the CST also needs an intravenous line and oxytocin infusion.
Choice C reason: The NST does not have fewer false-positive results than the CST, as it has a higher rate of nonreactive results that may indicate fetal compromise when there is none. A nonreactive NST is one that does not show at least two accelerations of the fetal heart rate of 15 beats per minute or more lasting 15 seconds or more in a 20-minute period.
Choice D reason: The NST is not more sensitive in detecting fetal compromise than the CST, as it has a lower predictive value for fetal well-being. A reactive NST is one that shows at least two accelerations of the fetal heart rate of 15 beats per minute or more lasting 15 seconds or more in a 20-minute period. However, a reactive NST does not rule out the possibility of fetal hypoxia or acidosis.
Correct Answer is C
Explanation
Choice A reason: The order in which the information is presented is not the most important factor, as it does not affect the client's motivation or ability to learn. The order of the information should be logical and sequential, but it can vary depending on the client's needs, preferences, and learning style. The nurse should assess the client's prior knowledge and tailor the teaching accordingly.
Choice B reason: The extent to which the pregnancy was planned is not the most important factor, as it does not determine the client's interest or willingness to learn. The pregnancy may be planned or unplanned, but the client may still have questions, concerns, or goals related to the pregnancy. The nurse should respect the client's feelings and emotions and provide support and guidance.
Choice C reason: The client's readiness to learn is the most important factor, as it influences the client's engagement and retention of the information. The client's readiness to learn depends on the client's perception of the relevance, importance, and benefits of the information, as well as the client's physical, psychological, and social readiness. The nurse should assess the client's readiness to learn and use appropriate strategies to enhance it, such as setting realistic and specific objectives, providing positive feedback, and involving the client in the learning process.
Choice D reason: The client's educational background is not the most important factor, as it does not reflect the client's learning needs or capabilities. The client's educational background may vary, but the client may still have similar or different learning needs depending on the pregnancy situation. The nurse should not assume the client's level of understanding or knowledge based on the client's educational background, but rather use simple and clear language, avoid medical jargon, and check for comprehension.
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