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 B
Explanation
Choice A reason: Human immunodeficiency virus (HIV) is a viral sexually transmitted infection that causes acquired immunodeficiency syndrome (AIDS). It is characterized by a progressive decline of the immune system, leading to opportunistic infections and cancers. It does not have recurrent episodes, but rather a chronic and incurable course.
Choice B reason: Herpes simplex virus (HSV)-2 is a viral sexually transmitted infection that causes genital herpes. It is characterized by a primary infection followed by recurrent episodes of painful blisters and ulcers in the genital area. The virus remains latent in the nerve cells and can reactivate periodically or in response to triggers such as stress, illness, or menstruation.
Choice C reason: Human papillomavirus (HPV) is a viral sexually transmitted infection that causes genital warts and cervical cancer. It is characterized by a persistent infection that may or may not produce symptoms. It does not have recurrent episodes, but rather a variable and unpredictable course.
Choice D reason: Cytomegalovirus (CMV) is a viral sexually transmitted infection that causes mild or asymptomatic infections in healthy adults. It is characterized by a latent infection that can reactivate in immunocompromised individuals, causing serious complications such as retinitis, pneumonia, or encephalitis. It does not have recurrent episodes, but rather a dormant and opportunistic course.
Correct Answer is C
Explanation
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.

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