A nurse is administering magnesium sulfate IV to a client with severe preeclampsia for seizure prophylaxis. Which of the following are indications of magnesium sulfate toxicity? (Select all that apply.)
Flushing and sweating.
Decreased level of consciousness.
Urinary output less than 30 mL/hr.
Respirations fewer than 12/min.
Correct Answer : A,B,C,D
Choice A rationale
Flushing and sweating can be an indication of magnesium sulfate toxicity. Magnesium sulfate is a medication used to prevent seizures in women with severe preeclampsia. However, if the levels of magnesium become too high, it can lead to toxicity15.
Choice B rationale
A decreased level of consciousness can be an indication of magnesium sulfate toxicity. High levels of magnesium can affect the central nervous system, leading to drowsiness, lethargy, and decreased responsiveness15.
Choice C rationale
Urinary output less than 30 mL/hr can be an indication of magnesium sulfate toxicity. Magnesium sulfate can affect kidney function, leading to decreased urine output15.
Choice D rationale
Respirations fewer than 12/min can be an indication of magnesium sulfate toxicity. High levels of magnesium can depress the respiratory system, leading to slow or shallow breathing15.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While an ASO titer test can be used in the diagnosis of rheumatic fever, it does not directly indicate if a child has rheumatic fever. Rheumatic fever is a complication that can occur after a streptococcal infection, and it involves multiple systems in the body, not just the presence of streptococcal antibodies.
Choice B rationale
An ASO titer test measures the antibodies produced by your body in response to a toxin known as streptolysin O, which is produced by group A Streptococcus (GAS) bacteria. Your body makes the antistreptolysin O antibodies when you have a strep infection caused by GAS bacteria. Therefore, a positive ASO titer test can confirm if your child had a recent streptococcal infection.
Choice C rationale
An ASO titer test does not measure the blood level of an aminoglycoside or any other therapeutic drug. Aminoglycosides are a class of antibiotics used to treat bacterial infections, and their levels in the blood are typically monitored with specific drug level tests, not an ASO titer.
Choice D rationale
An ASO titer test does not confirm if your child has immunity to streptococcal bacteria. The presence of ASO antibodies indicates a recent infection, but it does not provide information about the immune status or protection against future infections.
Correct Answer is A
Explanation
Choice A rationale
The nurse should reassure the patient by informing her about the hospital’s capabilities to handle such situations. The neonatal unit in the hospital is equipped to handle emergencies and care for preterm babies. This response is factual and directly addresses the patient’s concern about the baby’s well-being.
Choice B rationale
While it’s true that everyone worries about their baby when they’re in labor, this response doesn’t directly address the patient’s concern about the baby’s health and well-being. It’s more of a general statement and doesn’t provide the reassurance the patient is seeking.
Choice C rationale
This response acknowledges the patient’s feelings, which is an important aspect of patient care. However, it doesn’t provide any information or reassurance about the baby’s health. The patient is specifically asking about the baby’s well-being, so the response should focus on that.
Choice D rationale
This response could be misleading. While it’s true that the chances of survival for preterm babies improve with each passing week, it’s not guaranteed that a baby born at 32 weeks will be fine. It’s important to provide accurate information and not give false reassurances.
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