A pregnant woman has been receiving a magnesium sulfate infusion for the treatment of severe preeclampsia for 24 hours.
On assessment, the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus.
The patient complains, “I’m so thirsty and warm.” The nurse:
Calls for a stat magnesium sulfate level
Administers oxygen
Discontinues the magnesium sulfate infusion
Prepares to administer hydralazine
The Correct Answer is C
The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing.
Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely.
The nurse should stop the infusion immediately and notify the provider.
Choice A is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity.
The nurse should act quickly to prevent further complications.
Choice B is wrong because administering oxygen will not reverse the effects of magnesium toxicity.
Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.
Choice D is wrong because hydralazine is an antihypertensive medication that lowers blood pressure.
The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg).
Hydralazine may cause hypotension and fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The child should receive his regular dose of insulin even if he does not have an appetite. If the child is not eating as usual, he needs calories to prevent hypoglycemia. During periods of minor illness, the child with type 1 diabetes mellitus can be managed safely at home.
Choice A is wrong because giving the child half his regular morning dose of insulin can lead to hyperglycemia and ketoacidosis.
Choice C is wrong because giving the child plenty of unsweetened, clear liquids to prevent dehydration can also cause hypoglycemia.
Choice D is wrong because taking the child directly to the emergency department is not necessary unless the child has signs of severe dehydration, vomiting, abdominal
Correct Answer is D
Explanation
This pattern is called periodic breathing and it is characterized by 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration. It is a normal phenomenon that occurs primarily in premature infants of more than 24 hours of age. It is usually not of pathologic significance and does not require intervention.
Choice A is wrong because sleep or wakeful apnea is defined as a cessation of breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.
Choice B is wrong because severe swings in blood pressure are not associated with periodic breathing, but rather with intraventricular hemorrhage or patent ductus arteriosus.
Choice C is wrong because trying to maintain a neutral thermal environment does not affect the respiratory pattern of premature infants.
Normal ranges for respiratory rate in premature infants are 40 to 60 breaths per minute. Normal ranges for oxygen saturation in premature infants are 88% to 92%.
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