A woman is being treated for preterm labor with magnesium sulfate. Which finding by the nurse indicates magnesium sulfate toxicity?
Select one:

Respiratory rate of 16.

Complaints by the client of feeling ﬂushed and warm.

Fetal heart rate of 120.

Patellar reﬂexes are absent.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Respiratory rate of 16. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Respiratory rate is a measure of the number of breaths per minute, which reﬂects the respiratory function and oxygenation status. Respiratory rate of 16 is within the normal range for adults, which is 12 to 20 breaths per minute. Respiratory rate of 16 does not indicate magnesium sulfate toxicity, which can cause respiratory rate below 12 breaths per minute.

Choice B Reason: Complaints by the client of feeling ﬂushed and warm. This is an incorrect answer that indicates a common side eﬀect that does not indicate magnesium sulfate toxicity. Feeling ﬂushed and warm are sensations that are caused by vasodilation (widening of blood vessels), which can occur as a result of magnesium sulfate administration. Feeling ﬂushed and warm are not signs of magnesium sulfate toxicity, but rather expected and mild reactions that usually subside within a few hours.

Choice C Reason: Fetal heart rate of 120. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Fetal heart rate is a measure of the number of beats per minute of the fetal heart, which reﬂects the fetal well-being and oxygenation status. Fetal heart rate of 120 is within the normal range for fetuses, which is 110 to 160 beats per minute. Fetal heart rate of 120 does not indicate magnesium sulfate toxicity, which can cause fetal heart rate below 110 beats per minute or above 160 beats per minute.

Choice D Reason: Patellar reﬂexes are absent. This is because absent patellar reﬂexes are a sign of magnesium sulfate toxicity, which is a condition where the level of magnesium in the blood is too high, which can cause adverse eﬀects on the neuromuscular and cardiovascular systems. Magnesium sulfate is a medication that is used to prevent or treat preterm labor, which is labor that occurs before 37 weeks of gestation. Magnesium sulfate works by relaxing the uterine muscles and inhibiting uterine contractions. However, magnesium sulfate can also aﬀect other muscles and nerves in the body, and cause symptoms such as muscle weakness, respiratory depression, hypotension, or cardiac arrest.

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Correct Answer is D

Explanation

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

A. Place the infant skin to skin with the mother and re-check temperature in 30 minutes. B. Check the infant's CBC and blood cultures, as this is a sign of probable sepsis. C. Return the infant to the nursery for close observation under warming lights. D. Notify the physician immediately and suggest orders for placement in an incubator.

Correct Answer is A

Explanation

Choice A Reason: Place the infant skin to skin with the mother and re-check temperature in 30 minutes. This is because skin-to-skin contact is an eﬀective and safe method of increasing the infant's temperature and promoting thermoregulation. Skin-to-skin contact also has other benefits such as enhancing bonding, breastfeeding, and maternal-infant attachment.

Choice B Reason: Check the infant's CBC and blood cultures, as this is a sign of probable sepsis. This is an unnecessary action that may cause undue stress and discomfort to the infant and the mother. A slightly decreased temperature in a full-term infant is not a sign of probable sepsis, but rather a common finding that may be due to environmental factors, such as exposure to cold air or wet linens.

Choice C Reason: Return the infant to the nursery for close observation under warming lights. This is an undesirable action that may interfere with the early initiation of breastfeeding and bonding between the mother and the infant. Warming lights are not recommended for routine use in healthy newborns, as they may cause dehydration, hyperthermia, or eye damage.

Choice D Reason: Notify the physician immediately and suggest orders for placement in an incubator. This is an excessive action that may indicate a lack of knowledge or confidence on the part of the nurse. An incubator is not indicated for a stable, full term infant with a slightly decreased temperature, as it may expose the infant to unnecessary interventions, infections, or separation from the mother.

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A woman is being treated for preterm labor with magnesium sulfate. Which finding by the nurse indicates magnesium sulfate toxicity? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Select one:

Correct Answer is D

Explanation

The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to: Select one:

Correct Answer is A

Explanation

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A woman is being treated for preterm labor with magnesium sulfate. Which finding by the nurse indicates magnesium sulfate toxicity?
Select one: