The client at 25 weeks gestation in preterm labor has developed pre-eclampsia.
After receiving Nifedipine to stop her contractions, she is started on magnesium sulfate to control her pre-eclampsia.
When assessing the client, which findings by the nurse indicate that the client is experiencing an adverse effect from the magnesium sulfate? (Select all that apply).
Respiratory rate of 8 breaths per minute.
Blood pressure of 150/90 mmHg.
Lung crackles.
Increase in fetal heart rate.
Deep tendon reflexes.
Confusion.
Urine output of 30 mL in 2 hours.
Correct Answer : A,F,G
Choice A rationale
Respiratory rate of 8 breaths per minute indicates respiratory depression, a serious adverse effect of magnesium sulfate toxicity. Magnesium sulfate can depress neuromuscular transmission, leading to decreased respiratory effort and rate.
Choice B rationale
Blood pressure of 150/90 mmHg is not indicative of magnesium sulfate toxicity. Elevated blood pressure is a symptom of pre-eclampsia and not directly related to the adverse effects of magnesium sulfate. Therefore, it does not indicate toxicity.
Choice C rationale
Lung crackles are typically associated with fluid overload or heart failure rather than magnesium sulfate toxicity. While it is a serious condition, it is not specifically an adverse effect of magnesium sulfate.
Choice D rationale
Increase in fetal heart rate is not a common adverse effect of magnesium sulfate. Fetal heart rate changes are more commonly related to the underlying maternal condition or other medications used in pregnancy rather than magnesium sulfate.
Choice E rationale
Deep tendon reflexes would typically be decreased or absent in magnesium sulfate toxicity. Therefore, presence of deep tendon reflexes would not indicate an adverse effect of magnesium sulfate.
Choice F rationale
Confusion can occur due to central nervous system depression caused by high levels of magnesium sulfate. This is a significant adverse effect indicating possible toxicity.
Choice G rationale
Urine output of 30 mL in 2 hours suggests oliguria, which can be a sign of magnesium sulfate toxicity as the drug is excreted through the kidneys. Reduced urine output can indicate the kidneys are not clearing the drug efficiently, leading to toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Infection risk is generally higher postpartum rather than during the third stage of labor.
Choice B rationale
Fetal hypoxia is a concern during labor, but the third stage is more focused on delivery of the placenta.
Choice C rationale
Deep vein thrombosis is a longer-term postpartum concern, not specifically high risk in the third stage of labor.
Choice D rationale
Incomplete delivery of the placenta can lead to hemorrhage and is a primary concern in the third stage of labor.
Correct Answer is D
Explanation
Choice A rationale
Administering oxytocin is not appropriate at this stage since the fetal head at a +5 station indicates imminent delivery.
Choice B rationale
Applying fundal pressure is not recommended and can cause complications such as uterine rupture or maternal injury.
Choice C rationale
Suctioning the mouth of the infant at the perineum should be done only after the head is delivered to clear airway obstructions.
Choice D rationale
Observing for the presence of a nuchal cord is crucial as it can cause complications during delivery, requiring immediate attention.
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