A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.
As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?
Pain in the abdomen, shoulder, or back.
Respiratory depression, hypotension, absent tendon reflexes.
Severe lower back pain, leg cramps, sweating.
Low potassium or elevated glucose, tachycardia, chest pain.
The Correct Answer is B
Choice A rationale
Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.
Choice B rationale
Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.
Choice C rationale
Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.
Choice D rationale
Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A firm fundus displaced to the right and above the umbilicus often indicates a full bladder. The bladder, when distended, can push the uterus out of its midline position and interfere with its ability to contract effectively, potentially leading to increased bleeding. Having the client void will relieve the pressure on the uterus, allowing it to return to its midline position and remain firm.
Choice B rationale
Starting a pad count is a useful way to quantify the amount of lochia, but it does not address the immediate issue of the displaced fundus and potential bladder distention. It would be a subsequent step to monitor the bleeding after addressing the fundal position.
Choice C rationale
While fundal massage is appropriate for a soft or boggy uterus, the assessment indicates the fundus is already firm. Massaging a firm uterus is not the priority and will not address the displacement caused by a likely full bladder.
Choice D rationale
Notifying the healthcare provider is necessary if the fundus remains displaced and elevated after the client voids, as this could indicate other complications. However, the initial action should be to address the most likely cause, which is bladder distention.
Correct Answer is B
Explanation
Choice A rationale
Cocaine is a stimulant that typically causes fetal tachycardia (an elevated fetal heart rate) due to its sympathomimetic effects, increasing maternal and subsequently fetal heart rate and blood pressure. It does not usually lead to fetal bradycardia.
Choice B rationale
Prolonged umbilical cord compression can lead to fetal bradycardia because it restricts oxygenated blood flow to the fetus. The baroreceptors in the fetus respond to decreased oxygen by slowing the heart rate in an attempt to conserve oxygen and maintain perfusion to vital organs.
Choice C rationale
Fetal anemia, a decrease in red blood cell count, can lead to fetal tachycardia as the heart attempts to compensate for reduced oxygen-carrying capacity by increasing cardiac output. Bradycardia is not a typical initial response to fetal anemia.
Choice D rationale
Terbutaline is a tocolytic medication used to relax the smooth muscle of the uterus and prevent preterm labor. Its side effects often include maternal and fetal tachycardia due to its beta-adrenergic agonist activity.
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