A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy. For which of the following adverse effects should the nurse monitor and report to the provider?

Hyporeflexia

Tachypnea

Polyuria

Agitation

Answer and Explanation

The Correct Answer is A

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

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Correct Answer is D

Explanation

A: The recommended needle length for administering vaccines to newborns is usually ⅝ inch, but the needle choice can vary depending on the infant's size and age.
B: The preferred site for administering vaccines to infants is the vastus lateralis muscle in the anterolateral thigh, not the dorsal gluteal muscle.
C: The gauge of the needle can vary, and a 20-gauge needle may be appropriate depending on the specific vaccine and infant's size.
D: The standard dose for the hepatitis B vaccine for newborns is 0.5 mL.

A. Decreased muscle tone B. Exaggerated Moro reflex C. Consoles easily D. Weak cry

Correct Answer is B

Explanation

A. Decreased muscle tone is not typically associated with neonatal abstinence syndrome.
B. Exaggerated Moro reflex, which is a startle response that causes the baby to fling their arms and legs out and then curl them in, is a common signof neonatal abstinence
C. Consoling easily is not a characteristic feature of neonatal abstinence syndrome; these infants are often difficult to console.
D. A high pitched cry is a common symptom of neonatal abstinence syndrome. A weak cry is not anticipated.

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A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy. For which of the following adverse effects should the nurse monitor and report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer the hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Which of the following symptoms should the nurse recognize as a manifestation of neonatal abstinence syndrome?

Correct Answer is B

Explanation

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