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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client whose newborn is having difficulty latching-on should be addressed, but this issue is not an immediate postpartum emergency. It is important but does not require urgent intervention compared to potential complications from magnesium sulfate.
B. A client who received magnesium sulfate during labor should be seen first because magnesium sulfate can cause significant side effects like respiratory depression, decreased reflexes, and altered mental status. These effects require close monitoring to prevent severe complications.
C. A client who has a history of oligohydramnios requires monitoring but this history does not necessarily indicate an immediate postpartum issue requiring urgent assessment at this time.
D. A client whose labor lasted for 6 hr does not have an immediate concern solely based on labor duration. While it is relevant, it does not indicate an urgent need for assessment compared to the effects of magnesium sulfate.
Correct Answer is []
Explanation
- Potential Condition: Hyperemesis Gravidarum
Actions to take
- Insert a peripheral venous access device:
- Monitor and manage electrolyte values:
Parameters to monitor
- Electrolyte values:
- Urine ketones:
Rationale
- Potential Condition: Hyperemesis Gravidarum
- This condition is characterized by severe nausea and vomiting, leading to dehydration and nutrient loss, which can affect both the mother and fetus.
- Actions to Take:
1. Insert a peripheral venous access device:
- This will allow for the administration of IV fluids and medications to treat dehydration and correct electrolyte imbalances.
2. Monitor and manage electrolyte values:
- Given the client's low potassium levels, it's crucial to monitor and manage electrolytes to prevent complications.
- Parameters to Monitor:
1. Electrolyte values:
- Monitoring electrolyte levels is essential to ensure they are within normal ranges and to adjust IV fluid composition as needed.
2. Urine ketones:
- Positive urine ketones indicate that the body is using fat for energy due to inadequate glucose utilization, which is common in Hyperemesis Gravidarum. Monitoring will help assess the effectiveness of treatment and nutritional status.
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