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: A blood pressure increase to 138/86 mm Hg is not a concerning finding for preeclampsia. The diagnostic criteria for preeclampsia include a BP of 140/90 mm Hg or higher on two occasions at least 4 hours apart, or a BP of 160/110 mm Hg or higher on one occasion.
Choice B reason: Pitting pedal edema at the end of the day is not a concerning finding for preeclampsia. Edema is a common symptom of pregnancy and can be influenced by factors such as hydration, activity, and posture. Edema is not a reliable indicator of preeclampsia.
Choice C reason: Weight gain of 0.5 kg during the past 2 weeks is not a concerning finding for preeclampsia. The recommended weight gain for a normal-weight woman during pregnancy is 11.5 to 16 kg, with an average of 0.4 kg per week in the second and third trimesters.
Choice D reason: A dipstick value of 3+ for protein in her urine is a concerning finding for preeclampsia. Proteinuria is one of the hallmark signs of preeclampsia and indicates renal impairment. A dipstick value of 3+ corresponds to a protein concentration of 300 mg/dL or higher, which is considered severe.
Correct Answer is D
Explanation
Choice A reason: Hypoinsulinemia is not a major neonatal complication of the infant of a diabetic mother. It is a condition of low insulin levels in the blood, which can cause hyperglycemia.
Choice B reason: Hypercalcemia is not a major neonatal complication of the infant of a diabetic mother. It is a condition of high calcium levels in the blood, which can cause muscle weakness, confusion, and kidney stones.
Choice C reason: Hypobilirubinemia is not a major neonatal complication of the infant of a diabetic mother. It is a condition of low bilirubin levels in the blood, which can cause pale skin and eyes.
Choice D reason: Hypoglycemia is a major neonatal complication of the infant of a diabetic mother. It is a condition of low blood sugar levels, which can cause seizures, lethargy, and brain damage.
Choice E reason: None of the above is not a correct answer. There is one major neonatal complication of the infant of a diabetic mother, which is hypoglycemia.
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