A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?
Urine output 20 mL/hr.
Hypertension.
Hyperglycemia.
Respiratory rate 16/min.
The Correct Answer is A
Choice A rationale:
This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.
Choice B rationale:
Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.
Choice C rationale:
Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.
Choice D rationale:
A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Heart rate 72/min.
Choice A rationale:
A blood pressure of 80/50 mm Hg is within the normal range for a full-term newborn.
Choice B rationale:
A respiratory rate of 55/min is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute.
Choice C rationale:
A heart rate of 72/min is significantly lower than the normal range for a newborn, which is typically between 120 to 160 beats per minute. This bradycardia should be reported to the provider as it may indicate an underlying issue.
Choice D rationale:
A temperature of 36.5°C (97.7°F) is within the normal range for a newborn, which is generally between 36.5°C to 37.5°C (97.7°F to 99.5°F).
Correct Answer is B
Explanation
Choice A rationale:
A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.
Choice B rationale:
Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.
Choice C rationale:
A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.
Choice D rationale:
Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.
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