The nurse is caring for a 30-week gestation client who was loaded on a magnesium sulfate infusion one hour ago for preterm labor. Which of the following assessment findings would warrant the infusion to be discontinued immediately?
Blood pressure of 138/88.
Urinary output of 40 ml/hr.
Respiratory rate of 10 breaths/minute.
Patellar reflex of +2.
The Correct Answer is C
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse's first action should be to massage the woman's fundus. A completely saturated perineal pad within 15 minutes after giving birth indicates excessive bleeding, which is also known as postpartum hemorrhage (PPH). Massaging the uterus (fundus) can help it to contract, reduce bleeding, and prevent further blood loss. Once the fundus has been massaged, the nurse should assess the woman's vital signs and continue to monitor her for signs of continued bleeding. If bleeding persists despite massage, the nurse should begin an intravenous (IV) infusion of Ringer's lactate solution and call the woman's primary healthcare provider.
Correct Answer is C
Explanation
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
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