Your patient is receiving magnesium sulfate for neuroprotection and preterm labor at 1 gram/hour. The most concerning vital sign below is:

Heart rate of 99

Respiratory rate of 9

BP of 99/69

Temperature of 99.9

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not the most concerning vital sign because a heart rate of 99 is within the normal range for an adult. The nurse should monitor the patient's heart rate and rhythm, but it is not a sign of magnesium toxicity or adverse effects.

Choice B reason: This is the most concerning vital sign because a respiratory rate of 9 is below the normal range for an adult and indicates respiratory depression, which is a sign of magnesium toxicity. The nurse should stop the infusion, notify the provider, and prepare to administer calcium gluconate as an antidotE.

Choice C reason: This is not the most concerning vital sign because a BP of 99/69 is within the normal range for an adult. The nurse should monitor the patient's blood pressure and fluid status, but it is not a sign of magnesium toxicity or adverse effects.

Choice D reason: This is not the most concerning vital sign because a temperature of 99.9 is within the normal range for an adult. The nurse should monitor the patient's temperature and infection signs, but it is not a sign of magnesium toxicity or adverse effects.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action because a full bladder can cause the uterus to be displaced and prevent it from contracting properly, leading to uterine atony and excessive bleedinG. Asking the client to empty her bladder can help the fundus to return to the midline and reduce the lochiA.

Choice B reason: This is not the correct action because the client's temperature is within the normal range for the first 24 hours postpartum. A slight elevation in temperature can be due to dehydration, exertion, or milk production. The nurse should monitor the client's temperature and encourage fluid intake, but it is not a priority action.

Choice C reason: This is not the correct action because increasing IV fluids can cause fluid overload and worsen the bleedinG. The nurse should assess the client's fluid status and adjust the IV rate accordingly, but it is not a priority action.

Choice D reason: This is not the correct action because encouraging the client to nurse more frequently can stimulate oxytocin release and cause more uterine contractions and bleedinG. The nurse should support the client's breastfeeding practices, but it is not a priority action.

A. Maturity of lungs B. Gender of the fetus C. Anatomic abnormalities D. Weeks of gestation

Correct Answer is A

Explanation

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Your patient is receiving magnesium sulfate for neuroprotection and preterm labor at 1 gram/hour. The most concerning vital sign below is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is experiencing preterm labor and is scheduled to undergo amniocentesis for L/S ratio. The client needs an amniocentesis to determine which of the following findings?

Correct Answer is A

Explanation

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