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"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity. A higher ratio indicates that the baby's lungs are mature enough to handle breathing air outside the womb, which is the primary purpose of this test.
B. The L/S ratio test does not assess placental function. Placental function is evaluated through other tests, such as Doppler studies or biophysical profiles.
C. The L/S ratio test is not related to Rh incompatibility. Rh incompatibility issues are managed through different assessments, such as the Coombs test and Rh factor screening.
D. The L/S ratio test does not indicate genetic disorders. Genetic disorders are assessed through tests like amniocentesis or chorionic villus sampling, not the L/S ratio.
Correct Answer is B
Explanation
A. Notifying the provider may be necessary if the problem persists, but the first step is to address the most likely cause of the deviation.
B. A fundus that is firm but deviated to the left suggests that the bladder may be distended. Emptying the bladder can help the uterus to return to its midline position and promote proper uterine involution.
C. Monitoring perineal pads for clots is important, but the first action should be to resolve the potential cause of the fundal deviation.
D. Administering an analgesic is not a priority action for addressing fundal deviation.
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