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 B

Explanation

Choice A rationale

Diet cola, although refreshing, contains caffeine which can contribute to dehydration. For adolescents with sickle cell anemia, hydration is crucial to prevent sickle cell crises. Moreover, sodas generally offer no nutritional benefits.

Choice B rationale

Lemonade is a better choice as it is hydrating and provides fluids without caffeine. Proper hydration is vital for sickle cell patients to maintain blood volume and prevent the sickling of red blood cells. Additionally, lemonade can supply essential electrolytes.

Choice C rationale

Ice tea, similar to diet cola, contains caffeine which can exacerbate dehydration. Hydration is key for individuals with sickle cell anemia to avoid complications and maintain adequate blood flow.

Choice D rationale

Milkshake, while providing hydration, is high in fat and sugar, which can be counterproductive. It also lacks the electrolytes present in lemonade which are beneficial for maintaining fluid balance in the body.

A. Bleeding tendencies. B. Fluid balance. C. Heat loss. D. Hypoglycemia.

Correct Answer is C

Explanation

Choice A rationale

While bleeding tendencies can be a concern in newborns, especially if there are clotting disorders, it is not the immediate priority in the first minutes after birth. Immediate interventions focus on establishing effective respirations and ensuring adequate oxygenation.

Choice B rationale

Fluid balance is important for newborns, particularly in the context of hydration and potential complications like hypovolemia. However, the most immediate concern after birth is ensuring the newborn can breathe adequately to deliver oxygen to the body's tissues.

Choice C rationale

Heat loss is a critical issue for newborns, as they are at high risk for hypothermia due to their large surface area relative to body weight and limited ability to generate heat. Preventing heat loss helps to stabilize the newborn's temperature and supports overall physiological stability, including respiratory function.

Choice D rationale

Hypoglycemia can be a concern in newborns, particularly those who are small for gestational age or have other risk factors. However, the most immediate concern in the first minutes after birth is ensuring adequate breathing to support oxygenation and prevent complications related to hypoxia. .

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Naxlex Comprehensive Predictor Exams

Which drink choice on a hot day indicates to the nurse that an adolescent with sickle cell anemia understands dietary considerations related to the disease?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents.The child is anxious, has a temperature of 102.8°F (39.3°C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?

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