A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

Respiratory rate 11/min

Deep tendon reflexes 2+

Urine output 30 mL/hr

Blood pressure 100/62 mm Hg

Answer and Explanation

The Correct Answer is A

A. Respiratory rate 11/min: Correct. A respiratory rate of 11/min is below the normal range and could indicate magnesium sulfate toxicity, which can depress respiratory function. This finding requires prompt reporting to prevent further complications.

B. Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.

C. Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.

D. Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.

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Correct Answer is C

Explanation

A. Incorrect. Polyuria is not typically associated with epidural anesthesia. The adverse effects of epidurals are more related to cardiovascular and central nervous system impacts.

B. Incorrect. Epidural anesthesia generally causes hypotension, not hypertension, due to vasodilation.

C. Correct. Pruritus (itchiness) is a known adverse effect of epidural anesthesia, particularly if opioids are used in the epidural.

D. Incorrect. Dry mouth is not a common adverse effect of epidural anesthesia. It is more often associated with other medications or conditions.

A. Prepare the necessary equipment to initiate an amnioinfusion. B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord. C. Discontinue the infusion of oxytocin. D. Provide instructions for the client about potential preparation for birth.

Correct Answer is C

Explanation

A. Prepare the necessary equipment to initiate an amnioinfusion: Incorrect. While amnioinfusion may be considered for recurrent variable decelerations caused by umbilical cord compression, the priority is to address the immediate cause of the decelerations, which may be due to excessive oxytocin.

B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord: Incorrect. Although checking for umbilical cord prolapse is important, the first action should be to address any potential causative factors like oxytocin use before performing an examination.

C. Discontinue the infusion of oxytocin: Correct. Recurrent variable decelerations can be a sign of umbilical cord compression, often exacerbated by excessive uterine contractions induced by oxytocin. Discontinuing the infusion is a critical first step to alleviate the pressure on the umbilical cord and improve fetal heart rate patterns.

D. Provide instructions for the client about potential preparation for birth: Incorrect. Providing instructions about preparation for birth is important but does not address the immediate issue of recurrent variable decelerations and their potential cause.

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A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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