A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
Difficulty in arousing
Deep tendon reflexes 2+
Urinary output of 30 mL per hour
Respiratory rate of 10 breaths/minute
The Correct Answer is B
Choice A Reason: This is incorrect because difficulty in arousing is a sign of magnesium toxicity, which is a serious complication of magnesium sulfate therapy. Magnesium toxicity can cause central nervous system depression, muscle weakness, and cardiac arrest. The nurse should monitor the client's level of consciousness and stop the infusion if the client becomes lethargic or unresponsive.
Choice B Reason: This is correct because deep tendon reflexes 2+ indicate a normal and expected response to magnesium sulfate therapy. Magnesium sulfate is a muscle relaxant that can reduce the risk of seizures in gestational hypertension. The nurse should assess the client's deep tendon reflexes regularly and maintain them at 2+ or slightly diminished.
Choice C Reason: This is incorrect because urinary output of 30 mL per hour is below the normal range of 40 to 80 mL per hour and may indicate renal impairment or dehydration. Magnesium sulfate can cause renal toxicity or fluid retention, which can affect the urinary output. The nurse should monitor the client's urinary output and fluid balance and report any abnormalities to the doctor.
Choice D Reason: This is incorrect because respiratory rate of 10 breaths/minute is below the normal range of 12 to 20 breaths/minute and may indicate respiratory depression. Magnesium sulfate can cause respiratory depression or failure, which can be life-threatening. The nurse should monitor the client's respiratory rate and oxygen saturation and administer oxygen or antidote if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because gastrointestinal bleeding is not an adverse effect of hydralazine, which is a vasodilator that lowers blood pressure by relaxing the smooth muscles of the blood vessels. Gastrointestinal bleeding can be caused by other conditions such as ulcers, gastritis, or hemorrhoids.
Choice B Reason: This is incorrect because sweating is not an adverse effect of hydralazine, but a normal response to vasodilation and heat loss. Sweating can also be caused by other factors such as fever, anxiety, or exercise.
Choice C Reason: This is correct because tachycardia is an adverse effect of hydralazine, which can occur as a reflex response to vasodilation and hypotension. Tachycardia can increase the cardiac workload and oxygen demand, which can be harmful for pregnant women with preeclampsia who already have impaired placental perfusion and fetal hypoxia.
Choice D Reason: This is incorrect because blurred vision is not an adverse effect of hydralazine, but a symptom of severe preeclampsia that indicates cerebral edema or ischemia. Blurred vision can also be caused by other conditions such as diabetes, glaucoma, or cataracts.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because maternal diabetes is a condition where the mother has high blood sugar levels during pregnancy. It can cause polyhydramnios, or excess amniotic fluid, not oligohydramnios, or low amniotic fluid.
Choice B Reason: This is correct because fetal anencephaly is a congenital defect where the fetus lacks parts of the brain and skull. It can cause oligohydramnios, as the fetus does not produce enough urine to contribute to the amniotic fluid volume.
Choice C Reason: This is incorrect because placental abruption is a complication where the placenta detaches from the uterine wall before delivery. It can cause bleeding, pain, and fetal distress, but not oligohydramnios.
Choice D Reason: This is incorrect because neural tube defects are congenital defects where the spinal cord or brain does not develop properly. They can cause various neurological problems, but not oligohydramnios.
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