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:
Facilitate maternal-newborn interaction. Facilitating maternal-newborn interaction is an important aspect of breastfeeding, but it is not the primary purpose of encouraging breastfeeding immediately after an emergency birth. The primary purpose is to initiate the lactation cycle, allowing the newborn to receive essential colostrum, the first milk rich in antibodies and nutrients, which aids in the development of the newborn's immune system.
Choice B rationale:
Stimulate the uterus to contract. While breastfeeding can stimulate uterine contractions due to oxytocin release, the primary purpose of encouraging breastfeeding in this context is not to contract the uterus but to initiate the lactation cycle for the newborn's benefit.
Choice C rationale:
Prevent neonatal hypoglycemia. Breastfeeding can help prevent neonatal hypoglycemia by providing the newborn with a constant supply of nutrients, but the primary purpose immediately after an emergency birth is to initiate the lactation cycle and provide colostrum, not solely to prevent hypoglycemia.
Choice D rationale:
Initiate the lactation cycle. Initiating the lactation cycle is the correct answer because breastfeeding immediately after birth helps the woman's body start producing milk and provides the newborn with colostrum, essential for their health and development. Colostrum is rich in antibodies and nutrients, offering vital protection and nourishment to the newborn.
Correct Answer is B
Explanation
Choice A rationale:
Inspiratory stridor. Inspiratory stridor, a high-pitched sound heard during inhalation, is a common symptom of acute epiglottitis. It is caused by the swelling and inflammation of the epiglottis, which can partially obstruct the airway and create a stridor sound during breathing.
Choice B rationale:
Complete obstruction. Using a tongue depressor to examine the throat of a child with acute epiglottitis can potentially lead to a complete airway obstruction. The epiglottis, which is already swollen, can block the airway entirely, leading to respiratory distress and potentially a life-threatening situation.
Choice C rationale:
Sore throat. A sore throat is a common symptom of various respiratory tract infections, including acute epiglottitis. However, the use of a tongue depressor can worsen the swelling and potentially lead to complete airway obstruction, which is a more immediate concern.
Choice D rationale:
Respiratory tract infection. Acute epiglottitis itself is a severe respiratory tract infection, specifically involving the epiglottis. Using a tongue depressor might exacerbate the condition, leading to airway obstruction, but it is not the cause of the respiratory tract infection.
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