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

Answer and Explanation

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.

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Correct Answer is C

Explanation

This is because assessing fetal heart rate is the most important action to take first when a client has prelabor rupture of membranes (PROM) at 34 weeks of gestation and oligohydramnios.Fetal heart rate can indicate fetal well-being, distress, or infection.Oligohydramnios can increase the risk of umbilical cord compression and fetal hypoxia.

Choice A is wrong because administering IV fluids is not the first priority in this situation.IV fluids may be given to prevent dehydration, enhance uterine blood flow, or augment labor, but they are not as urgent as assessing fetal heart rate.

Choice B is wrong because obtaining a urine specimen is not the first priority in this situation.A urine specimen may be obtained to check for infection, proteinuria, or glucose levels, but they are not as urgent as assessing fetal heart rate.

Choice D is wrong because inserting an indwelling urinary catheter is not the first priority in this situation.An indwelling urinary catheter may be inserted to monitor fluid balance, prevent bladder distension, or reduce the risk of infection, but they are not as urgent as assessing fetal heart rate.

Normal ranges for fetal heart rate are 110 to 160 beats per minute.Oligohydramnios is defined as an amniotic fluid index of less than 5 cm.

A. Heart rate of 110/min B. Blood pressure of 150/90 mm Hg C. Blood glucose of 90 mg/dL D. Temperature of 37°C (98.6°F)

Correct Answer is B

Explanation

Blood pressure of 150/90 mmHg.This is because terbutaline can causeelevated blood pressureas a side effect.

The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.

Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline.Terbutaline can causefast or pounding heartbeatsas a common side effect.

Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals.Terbutaline can causetransient hyperglycemia(high blood sugar) as a serious side effect, but this is not the case here.

Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being.Terbutaline does not cause fever or hypothermia as a side effect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is in pre-term labor at 34 weeks of gestation and has ruptured membranes and oligohydramnios. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is assessing a client who is in pre-term labor and has received one dose of terbutaline subcutaneously. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

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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?