A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?
Positive clonus
Urinary output 20 mL/hr
Respiratory rate 10/min
Deep tendon reflexes 2+
The Correct Answer is D
A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.
B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.
C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.
D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client should use a hair dryer on a warm setting to relieve itching inside the cast is incorrect. Using a hair dryer could cause skin burns or damage the cast. Additionally, the client should avoid introducing moisture into the cast, which could lead to skin irritation or infection.
B. The client's extremity should be elevated after the cast is applied is correct. Elevating the extremity helps reduce swelling and inflammation during the initial phase after cast application. It is important to elevate the limb above the level of the heart to promote venous return and reduce swelling.
C. The client can shower with the cast after 24 hr is incorrect. The plaster cast should not get wet. The nurse should instruct the client to keep the cast dry at all times. A plastic cover or cast protector should be used when showering to prevent moisture from seeping into the cast.
D. The client should keep the cast covered until it is dry is incorrect. It is true that the cast should be kept dry, but keeping it covered is not enough. The primary concern is preventing moisture and ensuring the plaster cast is allowed to air dry in a well-ventilated area without getting wet.
Correct Answer is D
Explanation
A. "My child still wets the bed at least two times per week." While this is a concern, bedwetting can be a normal developmental behavior for children at this age and does not necessarily indicate a problem unless it persists beyond the typical age range.
B. "I have a difficult time getting my child to eat green vegetables." This is a common concern for parents of young children and typically does not warrant immediate attention, although it may require guidance on healthy eating habits.
C. "My child continually asks me the same questions." Repetition of questions is a normal part of cognitive development in young children and does not indicate an issue by itself.
D. "I have noticed that my child is withdrawn since we switched day care providers." This is the priority concern. Withdrawal or behavioral changes, particularly after a significant event like a change in day care, can indicate stress, anxiety, or possible emotional issues, and the nurse should address this promptly to ensure the child's well-being.
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