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 A
Explanation
A. A 10-year-old child who has sickle cell anemia who reports severe chest pain
Rationale:
A. A 10-year-old child who has sickle cell anemia who reports severe chest pain. Chest pain in a child with sickle cell anemia could indicate vaso-occlusive crisis, acute chest syndrome, or other serious complications requiring immediate assessment and intervention.
B. A PCO2 of 37 mm Hg in a 4-year-old child with asthma may indicate respiratory distress, but severe chest pain in a child with sickle cell anemia takes priority.
C. A urine specific gravity of 1.016 in a 7-year-old child with diabetes insipidus may indicate mild dehydration, but it does not require immediate assessment compared to severe chest pain.
D. A temperature of 39°C (102.2°F) in a 1-year-old toddler with roseola is concerning but does not take precedence over severe chest pain in a child with sickle cell anemi
A.
Correct Answer is B
Explanation
A. Frequent use of the call light does not necessarily indicate abuse. It could be due to various factors such as pain, discomfort, or needing assistance.
B. A child whose parents answer questions for the child may indicate potential parental control or intimidation, which can be a sign of emotional or psychological abuse.
C. Obesity alone does not necessarily indicate abuse. It could be due to various factors such as genetics, diet, or lack of physical activity.
D. Having frequent visitors does not necessarily indicate abuse. It could be due to a supportive social network or family involvement.
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