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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should keep the car seat rear-facing until your baby is at least 2 years old.": Correct. To ensure safety, it is recommended that infants remain in a rear-facing car seat until they are at least 2 years old, as this position provides better protection for their head, neck, and spine in the event of a crash.
B. "Position the retainer clip over the upper part of your baby's abdomen.": Incorrect. The retainer clip should be positioned at the level of the baby's armpits to provide proper restraint and safety.
C. "You should place your baby in the car seat at a 90-degree angle.": Incorrect. The car seat should be at a 45-degree angle to ensure that the baby’s head remains in a safe position and to prevent airway obstruction.
D. "Place the shoulder harness straps in the slots an inch above your baby's shoulders.": Incorrect. The harness straps should be positioned at or below the baby’s shoulders for rear-facing seats to provide proper restraint.
Correct Answer is D
Explanation
A. Request a prescription for PRN aspirin from the provider.: Incorrect. Aspirin should not be given with heparin as it can increase the risk of bleeding.
B. Massage the injection site thoroughly following administration.: Incorrect. The injection site should not be massaged after administering heparin to avoid irritation and potential hematoma formation.
C. Instruct the client that they cannot breastfeed while receiving heparin.: Incorrect. Heparin is generally considered safe to use during breastfeeding, so there is no need to instruct the client to stop breastfeeding.
D. Administer the injection in the client's abdomen.: Correct. Subcutaneous heparin injections are typically administered in the abdomen to facilitate absorption and minimize complications.
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