A client in preterm labor has had an infusion of magnesium sulfate running for 8 hours.
Current assessment findings are respirations of 14 breaths/minute, a urine output of 25 mL/hr, deep tendon reflexes of 1+, and a serum magnesium level of 8 mEq/L (4 mmol/L). Based on these assessment findings, which conclusion should the nurse reach?

These findings are within normal limits and require routine follow-up.

All findings are outside of the acceptable range and should be reported to the healthcare provider immediately.

The primary IV fluids should be increased to assist in increasing the urinary output.

The findings indicate potential toxicity to the magnesium sulfate and close follow-up is indicated.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.

Choice B rationale

Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.

Choice C rationale

Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.

Choice D rationale

The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A rationale

Requesting extra staff to help with the nursing assessments may not be the most effective approach. It could increase the child's anxiety due to the presence of more unfamiliar people in the room. The primary goal is to create a calm environment that helps the child feel safe and more cooperative.

Choice B rationale

Explaining the reasons for the examination to the child may not be effective for a preschooler who may not fully understand or be comforted by such explanations. Young children often require more tangible and immediate means of reassurance and distraction.

Choice C rationale

Talking to the mother and gradually focusing on the child's toy is a practical approach. This strategy helps build rapport with both the mother and the child, and using the toy as a focal point can distract and comfort the child, making the examination process less intimidating and more cooperative.

Choice D rationale

Completing the assessment while allowing the child to cry may not be ideal. It can increase the child's distress and make the assessment more challenging. Addressing the child's emotional needs by providing comfort and distraction can lead to a more successful and less stressful examination.

A. Encourage quiet activities such as watching television as a pain distracter. B. The child should be encouraged to rest when experiencing pain. C. The use of hot baths can be used as an alternative for pain medication. D. Giving pain medication around the clock helps control the pain.

Correct Answer is D

Explanation

Choice A rationale

While encouraging quiet activities like watching television can provide some distraction and temporary relief, it does not address the underlying need for consistent pain management in juvenile idiopathic arthritis. Distraction techniques should be used as an adjunct to proper pain medication rather than a replacement for it. This condition can cause chronic pain, which may negatively impact the child's quality of life if not managed appropriately.

Choice B rationale

Resting when experiencing pain is a common recommendation, but for juvenile idiopathic arthritis, it's essential to balance rest with physical activity to maintain joint mobility and muscle strength. Only encouraging rest can lead to muscle atrophy and joint stiffness, which can exacerbate the condition in the long term. Regular pain management can help the child stay more active.

Choice C rationale

Hot baths can help to some extent by relaxing muscles and reducing stiffness, but they are not sufficient as a sole method for managing pain in juvenile idiopathic arthritis. The condition often requires consistent medication to control inflammation and pain. Non-pharmacological methods like hot baths should be used in conjunction with prescribed medication rather than as an alternative.

Choice D rationale

Giving pain medication around the clock helps control the pain effectively by maintaining a steady level of medication in the body, preventing breakthrough pain. Consistent pain management allows the child to participate in daily activities and physical therapy, which is essential for maintaining joint function and overall quality of life.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for a client with preterm labor. The IV bag contains "Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.”. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?

During the admission process of a school-age child, the child states, "I'm going to have an operation.”. Which response is best for the nurse to provide to this child?

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?

The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?