A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia.
Which of the following findings should the nurse report to the provider?
Headache for 30 min
Fetal heart rate 158/min
Respirations 16/min
Urinary output 40 mL in 2 hr
The Correct Answer is D
Rationale:
A. Headache can be a common side effect of magnesium sulfate but is usually not concerning unless severe or persistent.
B. A fetal heart rate of 158/min is within the normal range for a fetus and is not typically associated with magnesium sulfate administration.
C. Respirations of 16/min are within the normal range and are not typically associated with magnesium sulfate administration.
D. A urinary output of 40 mL in 2 hours is significantly reduced and may indicate magnesium toxicity or impaired renal function, which should be reported to the provider for further
evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. This statement is overly dismissive and does not provide the client with accurate information about herbal therapies. Herbal therapies can have benefits for some individuals, but their efficacy and safety can vary widely.
B. "Many herbal products have not undergone long-term testing for safety and efficacy." This statement provides important information to the client about the potential risks associated with herbal therapies. It emphasizes the need for caution and informed decision-making when considering their use.
C. This statement is premature and does not address the need for further assessment or consideration of potential risks and benefits before starting herbal therapies.
D. This statement is inaccurate, as herbal therapies can have side effects and interactions with medications. It does not adequately inform the client about the potential risks associated with herbal therapies.
Correct Answer is D
Explanation
Rationale:
A. Asking a psychiatrist to talk with the parents may not be the most appropriate immediate
action when abuse is suspected. Reporting to the authorities should take precedence to ensure the child's safety.
B. Obtaining a detailed history is important but should be done after reporting the suspected abuse to the authorities.
C. Separating the child from the parents may not be feasible or appropriate in all situations.
Reporting to the authorities is the priority action to ensure proper investigation and protection of the child.
D. Report the suspected abuse to the authorities. Suspected child abuse must be reported
immediately to the appropriate authorities, such as child protective services or law enforcement, for further investigation and intervention to ensure the safety and well-being of the child.
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