A nurse is caring for a client who is in pre-term labor and receiving magnesium sulfate therapy.
The nurse should monitor the client for which of the following adverse effects of magnesium sulfate?
Hypertension
Hyperreflexia
Respiratory depression
Tachycardia
The Correct Answer is C
Magnesium sulfate is a drug that is used to prevent seizures associated with pre-eclampsia and to stop preterm labor. However, it can also cause adverse effects such as respiratory depression, which is a condition where the breathing rate becomes too slow and shallow.
Respiratory depression can be life-threatening for both the mother and the baby, so the nurse should monitor the client’s respiratory rate and oxygen saturation closely.
Choice A is wrong because magnesium sulfate can cause hypotension, not hypertension. Hypotension is low blood pressure, which can lead to dizziness, fainting, and shock.
Choice B is wrong because magnesium sulfate can cause hyporeflexia, not hyperreflexia. Hyporeflexia is a reduced or absent reflex response, which can indicate magnesium toxicity.
The nurse should check the client’s deep tendon reflexes regularly and stop the infusion if they are absent.
Choice D is wrong because magnesium sulfate can cause bradycardia, not tachycardia.
Bradycardia is a slow heart rate, which can reduce the blood flow to vital organs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Betamethasone is a corticosteroid that is given to pregnant women who are at risk of preterm labor to improve neonatal outcomes.Betamethasone stimulates the production of surfactant, a substance that lubricates the lungs and prevents them from collapsing after birth.This reduces the risk of respiratory distress syndrome, a common complication of preterm birth.
Choice B is wrong because betamethasone does not decrease the risk of infection in the newborn.In fact, it may increase the risk of maternal and neonatal infections by suppressing the immune system.
Choice C is wrong because betamethasone does not increase blood glucose levels in the newborn.However, it may cause transient hyperglycemia in the mother, which should be monitored and treated if necessary.
Choice D is wrong because betamethasone does not decrease the risk of bleeding in the newborn.It may increase the risk of intraventricular hemorrhage, a type of bleeding in the brain, if given before 24 weeks of gestation.Therefore, it should be used with caution in this population and only after a family’s decision regarding resuscitation.
Correct Answer is A
Explanation
Assess fetal heart rate and activity.
The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.
Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.
Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.
Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.
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