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?

"Respiratory rate 10/min"

"Urine output 40 mL/hr"

"Nausea"

"Facial flushing"

Answer and Explanation

The Correct Answer is A

A. A respiratory rate of 10/min indicates magnesium sulfate toxicity, which can cause respiratory depression. Close monitoring of respiratory rate is essential to identify and manage potential toxicity.
B. Urine output of 40 mL/hr is not an immediate sign of toxicity but requires monitoring. Decreased urine output can be a sign of complications, but it is not the primary indicator of magnesium sulfate toxicity.
C. Nausea is a common side effect of magnesium sulfate but not necessarily indicative of toxicity. More severe symptoms like respiratory depression are critical for diagnosing toxicity.
D. Facial flushing is a common, mild side effect of magnesium sulfate and not a sign of toxicity. Monitoring for more severe symptoms is essential to assess for toxicity.

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Correct Answer is A

Explanation

A. Counterpressure applied to the sacrum is effective for relieving low-back pain during labor. This technique can help alleviate discomfort associated with contractions and provide comfort to the laboring client.
B. Holding the breath during contractions is not recommended as it can decrease oxygen flow to the mother and baby. Breathing techniques that focus on relaxation and proper oxygenation are preferred.
C. Bed rest is not necessary for a client in early labor and can be counterproductive. Allowing the client to move and find comfortable positions is more beneficial during early labor.
D. An indwelling urinary catheter is not required in early labor unless there is a specific medical reason. Routine catheterization is not a standard part of early labor management.

A. "I will apply witch hazel pads after urination." B. "I will place a heat pack to the area several times a day." C. "I will use the numbing spray prior to cleansing the area." D. "I will remain in the sitz bath for 10 minutes."

Correct Answer is A

Explanation

A. Witch hazel pads can soothe the perineal area and reduce discomfort from an episiotomy and hemorrhoids. This is a common and effective part of postpartum perineal care.
B. Heat packs are not recommended for episiotomy care as they can increase swelling. Instead, cold packs or ice can be used to reduce swelling and discomfort.
C. Numbing sprays should not be used prior to cleansing the area. Instead, gentle cleaning with mild soap and water is recommended for postpartum perineal care.
D. A sitz bath should typically be used for 15 to 20 minutes, not just 10 minutes, to effectively soothe the perineal area and promote healing.

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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 contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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