A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings is the nurse's priority?
Respiratory rate 10/min
2+ deep-tendon reflexes
3+ pedal edema
Urinary output 35 mL/hr
The Correct Answer is A
A. Respiratory rate 10/min. This is the priority finding because it suggests respiratory depression, a serious side effect of magnesium sulfate therapy. Magnesium acts as a CNS depressant, and a respiratory rate below 12/min is a potential sign of magnesium toxicity, which can lead to respiratory arrest if not promptly addressed.
B. 2+ deep-tendon reflexes. This indicates normal neuromuscular function and is actually a reassuring finding in a client receiving magnesium sulfate. Reflexes are typically monitored to detect early signs of toxicity, and a 2+ rating means the dose is likely therapeutic.
C. 3+ pedal edema. While significant, pedal edema is a common feature of preeclampsia and not directly related to magnesium sulfate toxicity. It should be monitored but does not require immediate action compared to respiratory compromise.
D. Urinary output 35 mL/hr. This is slightly above the minimum acceptable output of 30 mL/hr, indicating the kidneys are excreting adequately. While magnesium is excreted renally and output must be monitored, this value does not indicate an acute risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "The estimated blood loss was 250 milliliters." This is a relevant clinical detail that directly impacts the client’s postoperative care. It provides important information for ongoing assessment of fluid status, potential for anemia, and need for interventions.
B. "The client was intubated without complications." While important during surgery, this is less relevant in the postoperative period unless the intubation caused complications or the client remains intubated. It does not guide current nursing care.
C. "There was a total of 10 sponges used during the procedure." Sponge counts are part of surgical safety and accountability, but they are not typically necessary in nursing hand-off unless a retained item is suspected.
D. "The client is a member of the board of directors." This is not clinically relevant and could breach confidentiality or bias care. Hand-off reports should focus solely on the client’s medical condition and nursing care needs.
Correct Answer is D
Explanation
A. Trochanter roll. This device is used to prevent external rotation of the hips, especially in clients who are immobile or lying supine. It does not support the feet or ankles and does not prevent plantar flexion.
B. Abduction pillow. An abduction pillow is placed between the legs to maintain proper hip alignment, particularly after hip surgery. It is not designed to prevent foot drop or plantar flexion contractures.
C. Sheepskin heel pad. This provides skin protection and pressure relief to prevent pressure ulcers on the heels. While useful for comfort and skin integrity, it does not keep the foot in a neutral position to prevent contractures.
D. Footboard. A footboard is placed at the foot of the bed to help maintain the foot in dorsiflexion, thereby preventing plantar flexion contractures (also known as foot drop). It supports proper alignment and is the most appropriate device for this purpose in clients with limited mobility.
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