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 B
Explanation
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.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because Ortolani's sign is a test for hip dysplasia in infants, not a sign of pregnancy. It involves moving the infant's legs to check for a clicking sound in the hip joint.
Choice B Reason: This is incorrect because Chadwick's sign is a bluish or purplish discoloration of the cervix, vagina, and vulva during pregnancy, not a softening of the lower uterine segment. It is caused by increased blood flow to the pelvic area.
Choice C Reason: This is incorrect because Goodell's sign is a softening of the cervix during pregnancy, not a softening of the lower uterine segment. It is caused by increased vascularity and edema of the cervical tissue.
Choice D Reason: This is correct because Hegar's sign is a softening of the lower uterine segment or isthmus during pregnancy. It can be felt by bimanual examination around six to twelve weeks of gestation.
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