. 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. Assist in initiating IV access and administering IV fluid bolus: While IV fluids may be needed, the priority in this case is to address the umbilical cord prolapse, which poses an immediate risk to the baby.

B. Call for assistance immediately: Cord prolapse is an obstetric emergency that requires immediate assistance to prevent fetal hypoxia. Rapid response is crucial to save the baby.

C. Apply finger pressure to the presenting part: Although applying pressure to relieve compression on the cord is necessary, the first action should be to summon help to manage the emergency.

D. Administer oxygen at 10 L/min via a nonrebreather: Oxygen is important to improve maternal and fetal oxygenation, but calling for help is the immediate priority in this life-threatening situation.

A. Contraction lasting 85 seconds B. Fetal heart rate 100/min for a 10-min period C. Contraction resting period 35 seconds D. Four contractions in a 10-min period

Correct Answer is B

Explanation

A. Contraction lasting 85 seconds. While contractions longer than 90 seconds should be reported due to the risk of uterine hyperstimulation, an 85-second contraction is within normal limits.

B. Fetal heart rate 100/min for a 10-min period. A fetal heart rate of 100/min indicates bradycardia, which can signify fetal distress. Fetal bradycardia (below 110 beats per minute) lasting more than 10 minutes is an emergency.

C. Contraction resting period 35 seconds. A 35-second resting period between contractions is short but not abnormal enough to require immediate reporting unless accompanied by signs of fetal distress.

D. Four contractions in a 10-min period. Four contractions in 10 minutes is normal during active labor, where uterine activity is expected to increase.

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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

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