Magnesium Sulfate is being administered intravenously to a client for pregnancy-induced hypertension.
Which assessment finding should the nurse identify as a complication of this treatment?
Respiratory rate of 10 bpm.
Blood pressure of 148/94.
Deep tendon reflexes of +2.
Urine output of 70ml/hour.
The Correct Answer is A
Choice A rationale:
A respiratory rate of 10 bpm is significantly lower than the normal range for adults, which is typically 12-20 breaths per minute. This finding suggests respiratory depression, a potential complication of magnesium sulfate administration. Magnesium sulfate, when given intravenously, can lead to respiratory depression, hypotension, and loss of deep tendon reflexes. Monitoring respiratory rate is crucial to detect early signs of respiratory depression, allowing prompt intervention to prevent respiratory failure.
Choice B rationale:
A blood pressure of 148/94 mmHg is elevated and indicates hypertension. While hypertension is a known side effect of magnesium sulfate, a blood pressure reading alone is not specific enough to indicate a complication of treatment. It is essential to consider other vital signs and symptoms for a comprehensive assessment.
Choice C rationale:
Deep tendon reflexes of +2 are within the normal range and do not indicate a complication of magnesium sulfate administration. Hyperreflexia (exaggerated reflexes) is a sign of magnesium toxicity, but +2 reflexes are normal. Monitoring deep tendon reflexes is crucial, but the given value is within the normal range.
Choice D rationale:
An urine output of 70 ml/hour is within the normal range of urine output (30-60 ml/hour) for adults. While monitoring urine output is essential to assess renal function, this value does not indicate a complication of magnesium sulfate administration. Decreased urine output could suggest kidney injury, which is a potential complication of magnesium sulfate, but 70 ml/hour is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Pouring warm water over the perineum provides sensory stimulation that can trigger the micturition reflex. This is a non-invasive nursing intervention typically attempted before proceeding to more invasive measures.
Choice B rationale: Placing oil of peppermint in a bedpan is a traditional nursing measure. The aromatic vapors are thought to relax the pelvic floor muscles and urinary sphincter, facilitating spontaneous voiding.
Choice C rationale: Analgesics may reduce perineal pain that inhibits voiding, but they do not directly address a full bladder. Medications are generally not the "last resort" for immediate mechanical emptying of the bladder.
Choice D rationale: Urinary catheterization is an invasive procedure that carries a risk of infection. It is reserved as the final intervention when all non-invasive methods have failed to resolve bladder distention.
Correct Answer is C
Explanation
Choice A rationale:
Signs of stress can indeed manifest in various ways, including stomach pains and changes in behavior. However, in this scenario, the child's symptoms of stomach pains, aggression, and stubbornness might indicate a physical problem causing emotional stress. It's essential to consider other possibilities before attributing the symptoms solely to stress.
Choice B rationale:
Developmental delay could be a potential cause of behavioral issues in a child, but it doesn't explain the stomach pains. Moreover, a developmental delay would typically have been identified earlier in the child's life through regular screenings and assessments.
Choice C rationale:
A physical problem causing emotional stress, such as an undiagnosed medical condition, can lead to both stomach pains and behavioral changes. Considering this possibility is crucial in this situation. It's essential to conduct a thorough physical examination and medical evaluation to rule out any underlying health issues.
Choice D rationale:
Lack of adjustment to the school environment could contribute to behavioral problems in a child. However, it's essential to first investigate the physical symptoms, like stomach pains, before solely attributing the behavior to school adjustment issues. Physical health should be thoroughly assessed to rule out any medical causes for the symptoms.
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