A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
a sleepy, sedated affect.
absent ankle clonus.
a respiratory rate of 10 breaths/min.
deep tendon reflexes of 2+.
The Correct Answer is C
Choice A reason: A sleepy, sedated affect is not a concerning sign, as it is a common side effect of magnesium sulfate. Magnesium sulfate is a central nervous system depressant that can cause drowsiness, lethargy, and reduced alertness.
Choice B reason: Absent ankle clonus is not a concerning sign, as it indicates a normal neuromuscular response. Ankle clonus is a rhythmic jerking of the foot when the ankle is dorsiflexed. It is a sign of hyperreflexia, which can occur in severe preeclampsia due to increased blood pressure and cerebral edema.
Choice C reason: A respiratory rate of 10 breaths/min is a concerning sign, as it indicates respiratory depression. This is a serious complication of magnesium sulfate toxicity, which can lead to respiratory arrest and death. The nurse should monitor the woman's respiratory rate closely and report any signs of respiratory distress.
Choice D reason: Deep tendon reflexes of 2+ are not a concerning sign, as they indicate a normal neuromuscular response. Deep tendon reflexes are graded from 0 to 4, with 2 being the average. Magnesium sulfate can cause hyporeflexia or areflexia, which are signs of magnesium sulfate toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Syphilis is a bacterial STI caused by Treponema pallidum. It is characterized by three stages: primary, secondary, and tertiary. It can cause serious complications such as neurosyphilis, cardiovascular syphilis, and congenital syphilis. However, it is not the most common bacterial STI.
Choice B reason: Candidiasis is a fungal infection caused by Candida albicans. It is not a STI, but rather an opportunistic infection that can affect the vagina, mouth, skin, or other mucous membranes. It can cause symptoms such as itching, burning, discharge, and inflammation.
Choice C reason: Gonorrhea is a bacterial STI caused by Neisseria gonorrhoeae. It can infect the urethra, cervix, rectum, throat, or eyes. It can cause symptoms such as dysuria, discharge, pelvic pain, and bleeding. It can also lead to complications such as pelvic inflammatory disease, epididymitis, infertility, and disseminated gonococcal infection. However, it is not the most common bacterial STI.
Choice D reason: Chlamydia is a bacterial STI caused by Chlamydia trachomatis. It is the most common bacterial STI, affecting about 2.86 million people in the United States in 2018. It can infect the urethra, cervix, rectum, throat, or eyes. It can cause symptoms such as dysuria, discharge, pelvic pain, and bleeding. It can also lead to complications such as pelvic inflammatory disease, epididymitis, infertility, and ectopic pregnancy.
Correct Answer is A
Explanation
Choice A reason: A miscarriage is defined as a spontaneous abortion of a fetus before the 20th week of gestation. It is a natural pregnancy loss that occurs before labor begins and is usually caused by chromosomal abnormalities, infections, or maternal health problems.
Choice B reason: A miscarriage is not often attributed to careless maternal behavior such as poor nutrition or excessive exercise. These factors may affect the quality of life of the mother and the fetus, but they are not the main causes of miscarriage. Most miscarriages are not preventable and are not the fault of the mother.
Choice C reason: A miscarriage that occurs before the 12th week of pregnancy may manifest only as moderate discomfort and blood loss, but this is not always the case. Some women may experience severe cramping, bleeding, and tissue passing from the vagina. Others may have no symptoms at all and only discover the miscarriage during a routine ultrasound.
Choice D reason: A miscarriage occurs in more than 5% of all clinically recognized pregnancies. The actual rate of miscarriage is estimated to be 10% to 20%, but many women may not realize they are pregnant or may not report the loss to their health care provider.
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