A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Drowsiness

Facial flushing

Nausea

Respiratory depression

Answer and Explanation

The Correct Answer is D

Explanation:

A. Drowsiness: Mild drowsiness is a common side effect of magnesium sulfate therapy and is not necessarily indicative of toxicity. However, severe drowsiness or lethargy can be a sign of magnesium toxicity and should be reported to the provider.

B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate administration and is generally not a sign of toxicity. It is often accompanied by warmth and redness of the skin but is not considered a serious adverse reaction.

C. Nausea: Nausea is another common side effect of magnesium sulfate therapy and is usually mild and transient. It is not typically indicative of toxicity unless it is severe and persistent.

D. Respiratory depression: Respiratory depression is a critical sign of magnesium toxicity. Excessive levels of magnesium can affect neuromuscular function, leading to respiratory muscle weakness and depression. This can result in shallow or slowed breathing, decreased oxygenation, and potential respiratory failure. Respiratory depression is a serious complication that requires immediate intervention, and the nurse should report it to the provider promptly.

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Correct Answer is A

Explanation

Explanation:

A. Unilateral, cramp-like abdominal pain.

This is a typical manifestation of an ectopic pregnancy. The pain is often localized to one side of the lower abdomen and may be cramp-like or sharp. It occurs due to the stretching and irritation of surrounding structures, such as the fallopian tube, as the pregnancy grows outside of the uterus.

B. Severe nausea and vomiting.

While nausea and vomiting can occur during pregnancy, especially in the first trimester (morning sickness), they are not specific manifestations of an ectopic pregnancy. Severe nausea and vomiting are more commonly associated with conditions like hyperemesis gravidarum, but they are not indicative of an ectopic pregnancy.

C. Large amount of vaginal bleeding.

Vaginal bleeding can occur in ectopic pregnancies, but it is typically not a large amount compared to the bleeding seen in a miscarriage or other complications. Ectopic pregnancy bleeding is often lighter and may be accompanied by spotting or brownish discharge. However, significant vaginal bleeding is not a consistent manifestation of an ectopic pregnancy.

D. Uterine enlargement greater than expected for gestational age.

In an ectopic pregnancy, the fertilized egg implants outside of the uterus, so there is no uterine enlargement as expected in a normal intrauterine pregnancy. Therefore, uterine enlargement greater than expected for gestational age would not be consistent with an ectopic pregnancy.

A. Report of headache B. Polyuria C. Tachycardia D. Absence of clonus

Correct Answer is A

Explanation

Explanation:

A. Report of headache

Severe preeclampsia is characterized by hypertension (high blood pressure) along with other signs and symptoms of preeclampsia, such as proteinuria (protein in the urine) and end-organ dysfunction. Headache is a common symptom associated with severe preeclampsia and is often described as persistent and severe.

B. Polyuria

Polyuria, or excessive urination, is not typically associated with severe preeclampsia. In fact, decreased urine output (oliguria) can be a concern in severe cases due to reduced kidney function and fluid retention.

C. Tachycardia

Tachycardia, or a rapid heart rate, is not a typical finding in severe preeclampsia. In fact, hypertension and vascular constriction associated with preeclampsia can lead to normal or even lower heart rates in some cases.

D. Absence of clonus

Clonus refers to rhythmic, involuntary muscle contractions and relaxations. In the context of preeclampsia, the presence of clonus (especially hyperreflexia and positive clonus) is a concerning sign associated with central nervous system irritability and potential seizures. Absence of clonus would not be an expected finding in severe preeclampsia, as neurological manifestations such as hyperreflexia and clonus can occur in more severe cases.

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A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

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