The nurse is performing an assessment on a child and notes the presence of Koplik’s spots. In which communicable disease are Koplik’s spots present?

The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing.

Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely.

The nurse should stop the infusion immediately and notify the provider.

Choice A is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity.

The nurse should act quickly to prevent further complications.

Choice B is wrong because administering oxygen will not reverse the effects of magnesium toxicity.

Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.

Choice D is wrong because hydralazine is an antihypertensive medication that lowers blood pressure.

The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg).

Hydralazine may cause hypotension and fetal distress.

choice D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. This is because a macrosomic infant (a newborn who’s much larger than average) is at risk of developing low blood sugar levels after birth, especially if the mother has diabetes. Hypoglycemia can cause neurological damage in the newborn, so it is important to detect and treat it promptly.

Choice A is wrong because leaving the infant in the room with the mother without monitoring the blood glucose levels may miss signs of hypoglycemia and delay treatment.

Choice B is wrong because taking the infant immediately to the nursery may separate the infant from the mother and interfere with breastfeeding, which can help prevent hypoglycemia.

Choice C is wrong because performing a gestational age assessment to determine whether the infant is large for gestational age is not urgent and does not address the risk of hypoglycemia.

Normal ranges for blood glucose levels in term infants are 2.6 mmol/L or higher at any time. A blood glucose level of 2.5 mmol/L or less is considered hypoglycemic.