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 B
Explanation
Choice A reason: Infection is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Marginal placenta previa is a type of placenta previa where the edge of the placenta is near the cervical os but does not cover it. It can cause painless bleeding during pregnancy or labor, but it does not increase the risk of infection.
Choice B reason: Hemorrhage is the greatest risk for a woman with marginal placenta previa, as it can occur due to the separation of the placenta from the uterine wall during labor or delivery. The bleeding can be profuse and life-threatening, and it requires prompt intervention and monitoring.
Choice C reason: Urinary retention is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Urinary retention is the inability to empty the bladder completely, and it can occur due to various factors such as anesthesia, trauma, or medication. It can cause discomfort, infection, or bladder distension, but it is not as serious as hemorrhage.
Choice D reason: Thrombophlebitis is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Thrombophlebitis is the inflammation of a vein due to a blood clot, and it can occur due to prolonged bed rest, dehydration, or injury. It can cause pain, swelling, or redness in the affected area, and it can lead to pulmonary embolism if the clot dislodges and travels to the lungs. However, it is not as common or as severe as hemorrhage.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because a donor embryo is not used in IVF-ET. A donor embryo is an embryo that was created from another couple's gametes and donated to an infertile couple. IVF-ET uses the couple's own gametes to create an embryo.
Choice B reason: This is incorrect because it is dismissive and unprofessional. The nurse should respect the husband's curiosity and provide accurate and clear information about the procedure. The nurse should also address any concerns or questions that the couple may have.
Choice C reason: This is correct because it is a concise and accurate description of the IVF-ET procedure. The nurse explains the main steps and the purpose of the procedure in simple terms.
Choice D reason: This is incorrect because donor sperm is not used in IVF-ET. Donor sperm is sperm that was obtained from another man and donated to an infertile couple. IVF-ET uses the husband's own sperm to fertilize the wife's eggs.
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