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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

Answer and Explanation

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

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Correct Answer is B

Explanation

A way to establish rapport. Doing a simple magic trick using gauze is a way to gain the child’s trust and attention, and to make the dressing change less stressful and more fun. This is appropriate for a 5-year-old child who is in the stage of initiative versus guilt according to Erikson’s theory of psychosocial development.

Choice A is wrong because 5-year-old children are curious and imaginative, and they enjoy magic tricks and fantasy play.

Choice C is wrong because a simple magic trick is not too distracting, but rather a way to engage the child and reduce anxiety.

Choice D is wrong because a simple magic trick is not inappropriate due to the child’s cognitive development. According to Piaget’s theory of cognitive development, 5-year-old children are in the preoperational stage, which means they can use symbols and language to represent objects and events.

A magic trick using gauze is a symbolic representation of something else, which the child can understand and appreciate.

A. Inspiratory stridor B. Complete obstruction C. Sore throat D. Respiratory tract infection

Correct Answer is B

Explanation

If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place.

This is because the inflamed epiglottis can block the airway and cause respiratory distress or failure.

Choice A is wrong because inspiratory stridor is a sign of upper airway obstruction that is aggravated when a child with epiglottitis is supine.

It is not caused by examining the throat with a tongue depressor.

Choice C is wrong because sore throat and pain on swallowing are early signs of epiglottitis, not precipitated by examining the throat with a tongue depressor.

Choice D is wrong because respiratory tract infection is the cause of epiglottitis, not a symptom or condition that is precipitated by examining the throat with a tongue depressor.

Epiglottitis is caused by H. influenzae in the respiratory tract.

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Naxlex Comprehensive Predictor Exams

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as:

Correct Answer is B

Explanation

The nurse is assessing a child with acute epiglottitis. Examining the child’s throat by using a tongue depressor might precipitate which symptom or condition?

Correct Answer is B

Explanation

When caring for a child with Kawasaki disease, the nurse should understand that principle of care?

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The nurse is caring for a child with suspected diabetes insipidus. Which clinical manifestation would be observable?

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