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
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.
Correct Answer is A
Explanation
choice A.
Infant of an Rh-negative mother and a father who is Rh-positive and homozygous for the Rh factor.
Rh incompatibility occurs when a woman is Rh-negative and her baby is Rh-positive. This can cause hemolytic disease of the neonate (HDN), a condition where the mother’s antibodies destroy the baby’s red blood cells.
Choice B is wrong because if both the mother and the baby are Rh-negative, there is no risk of Rh incompatibility.
Choice C is wrong because if the father is heterozygous for the Rh factor, there is a 50% chance that the baby will be Rh-negative and not affected by Rh incompatibility.
Choice D is wrong because if both the mother and the baby are Rh-positive, there is no risk of Rh incompatibility.
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