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 B

Explanation

Explanation:

A. Slightly below the umbilicus:

Around 16-20 weeks of gestation, the fundal height is typically palpated slightly below the umbilicus. This corresponds to the level of the fundus before it starts rising significantly above the umbilicus as the pregnancy progresses.

B. 3 cm above the umbilicus:

At 22 weeks of gestation, the fundal height is expected to be approximately 3 cm above the umbilicus. This is a common estimation for the fundal height at this stage of pregnancy, as the uterus continues to grow and the fundus ascends in a predictable manner.

C. 3 cm below the umbilicus:

Palpating the fundus 3 cm below the umbilicus would typically correspond to an earlier gestational age, such as around 16-18 weeks. As pregnancy advances, the fundal height increases, and by 22 weeks, it should be well above the level of the umbilicus.

D. Slightly above the umbilicus:

This location is closer to where the fundal height is expected to be at later gestational ages, such as 24-26 weeks. However, at 22 weeks of gestation, the fundal height should not be palpated slightly above the umbilicus but rather around 3 cm above it.

A. Preeclampsia B. Puerperal infection C. Anaphylactoid syndrome of pregnancy D. Disseminated intravascular coagulation

Correct Answer is D

Explanation

Explanation:

A. Preeclampsia: Preeclampsia is a condition characterized by high blood pressure and signs of damage to other organs, typically occurring after 20 weeks of pregnancy. While preeclampsia is a concern during pregnancy, it is not directly related to abruptio placentae.

B. Puerperal infection: Puerperal infection refers to an infection that occurs after childbirth. Although infections are a concern in the postpartum period, they are not specifically associated with abruptio placentae unless there are additional risk factors or complications.

C. Anaphylactoid syndrome of pregnancy: Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) is a rare but serious condition where amniotic fluid enters the maternal circulation, potentially causing a severe allergic-like reaction. This condition is not directly related to abruptio placentae.

D. Disseminated intravascular coagulation: DIC is a serious condition where the body's clotting mechanisms are abnormally activated, leading to widespread clot formation in small blood vessels. This can lead to bleeding tendencies and the formation of small blood clots throughout the body. DIC can be a complication of abruptio placentae, especially when there is evidence of bleeding such as petechiae and bleeding around the IV access site. Therefore, it is a significant concern in this context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is B

Explanation

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Correct Answer is D

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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?