A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor.The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

Nausea.

Facial flushing.

Urine output 40 mL/hr.

Respiratory rate 10/min.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Nausea can be a side effect of magnesium sulfate, but it is not a specific indication of toxicity. Other symptoms are more directly indicative of magnesium sulfate overdose.

Choice B rationale

Facial flushing is a common side effect of magnesium sulfate but is not a sign of toxicity. It typically occurs at therapeutic levels and is not a reliable indicator of overdose.

Choice C rationale

Urine output of 40 mL/hr is within normal limits for an adult and does not indicate magnesium sulfate toxicity. However, significantly decreased urine output could be concerning.

Choice D rationale

Respiratory rate of 10/min is a critical sign of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a rate of 10 breaths per minute or less indicates that the patient may be experiencing toxic effects, necessitating immediate medical intervention.

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Correct Answer is A

Explanation

Choice A rationale

Respiratory rate of 10/min is a critical adverse effect, indicating potential respiratory depression due to magnesium sulfate, a serious and life-threatening condition requiring immediate intervention.

Choice B rationale

Urine output of 160 mL in 4 hours is lower than expected but not immediately life-threatening. It needs monitoring but is not as critical as respiratory rate.

Choice C rationale

Diaphoresis, or excessive sweating, can be a side effect of magnesium sulfate but is not life-threatening. It warrants attention but does not require immediate reporting.

Choice D rationale

Nausea is a common, less severe side effect of magnesium sulfate that does not indicate an urgent situation.

A. Cleanse the heel with an antiseptic. B. Cover the heel with an adhesive bandage. C. Puncture the heel and collect the blood. D. Apply pressure with a dry gauze pad. E. Wrap a warm, moist cloth around the heel.

Correct Answer is E,A,C,D,B

Explanation

Wrap a warm, moist cloth around the heel.
Cleanse the heel with an antiseptic.
Puncture the heel and collect the blood.
Apply pressure with a dry gauze pad.
Cover the heel with an adhesive bandage. .

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A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor.The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a prescription for magnesium sulfate.Which of the following adverse effects should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is E,A,C,D,B

Explanation

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