. nurse is assisting with the care of a client with PROM and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Heart rate of 55/min

Urine output of 50 mL in 4 hr

Diminished deep-tendon reflexes

Respiratory rate of 16/min

Answer and Explanation

The Correct Answer is D

A. Heart rate of 55/min. A heart rate of 55/min is bradycardia, which may indicate magnesium toxicity. This is a concerning sign and does not indicate safety to continue.

B. Urine output of 50 mL in 4 hr. A urine output of only 50 mL in 4 hours is too low (less than 30 mL/hr is concerning) and may indicate toxicity, since magnesium sulfate is excreted via the kidneys.

C. Diminished deep-tendon reflexes. Diminished deep-tendon reflexes (DTRs) may indicate magnesium toxicity. DTRs are monitored to assess for toxicity.

D. Respiratory rate of 16/min. A normal respiratory rate (12-20 breaths per minute) indicates that the magnesium sulfate has not caused respiratory depression, a sign of magnesium toxicity.

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Correct Answer is B

Explanation

A. Take the client's temperature. Monitoring the client's temperature for signs of infection is important, but it is not the priority immediately following an amniotomy. Infection typically develops over time.

B. Check the fetal heart rate pattern. The priority after an amniotomy is to assess the fetal heart rate to detect any signs of umbilical cord prolapse or fetal distress, which can occur immediately after rupture of membranes.

C. Observe the color and consistency of amniotic fluid. Although it is important to observe amniotic fluid for abnormalities (e.g., meconium staining), the immediate priority is fetal heart rate monitoring.

D. Evaluate the client for signs of infection. Signs of infection should be monitored, but they are not the priority right after amniotomy.

A. An artifact on the printout is very common B. Accurate information regarding FHR variability is not possible C. It cannot provide data about the uterine resting tone D. It is invasive and increases the risk for uterine infection

Correct Answer is A

Explanation

A. An artifact on the printout is very common. Artifacts are more common with external fetal monitoring, not internal fetal monitoring.

B. Accurate information regarding FHR variability is not possible. Internal fetal monitoring provides more accurate information about fetal heart rate (FHR) variability compared to external monitoring.

C. It cannot provide data about the uterine resting tone. Internal monitoring can measure the uterine resting tone more accurately than external methods.

D. It is invasive and increases the risk for uterine infection. Internal fetal monitoring requires inserting a device into the uterus, making it invasive and increasing the risk of infection.

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. nurse is assisting with the care of a client with PROM and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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