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 A
Explanation
Choice A reason: HSV-2 is a viral infection that causes genital herpes. It is transmitted through sexual contact and can cause painful blisters and ulcers in the genital area. The primary infection is usually the most severe and lasts for several weeks. After the primary infection, the virus remains dormant in the nerve cells and can reactivate periodically, causing recurrent episodes of genital herpes. The frequency and severity of the recurrences vary from person to person.
Choice B reason: HPV is a viral infection that causes genital warts and cervical cancer. It is transmitted through sexual contact and can infect the skin and mucous membranes of the genital area. The primary infection is often asymptomatic and may clear spontaneously or persist for years. HPV does not cause recurrent episodes of genital warts or cervical cancer, but it can increase the risk of developing these conditions over time.
Choice C reason: CMV is a viral infection that causes flu-like symptoms and can affect various organs. It is transmitted through bodily fluids such as saliva, urine, blood, and semen. The primary infection is usually mild and may go unnoticed. After the primary infection, the virus remains latent in the body and can reactivate in people with weakened immune systems, causing serious complications. CMV does not cause recurrent episodes of flu-like symptoms or organ damage, but it can worsen the condition of people with HIV or AIDS.
Choice D reason: HIV is a viral infection that causes acquired immunodeficiency syndrome (AIDS). It is transmitted through sexual contact, blood transfusion, or sharing of needles. The primary infection is often accompanied by flu-like symptoms and lasts for a few weeks. After the primary infection, the virus gradually destroys the immune system and makes the person vulnerable to opportunistic infections and cancers. HIV does not cause recurrent episodes of flu-like symptoms or AIDS, but it can progress to AIDS over time.
Correct Answer is A
Explanation
Choice A reason: A previous birth of a large infant (macrosomia) is a risk factor for gestational diabetes mellitus (GDM). A large infant may indicate that the mother had high blood glucose levels during pregnancy, which can cause the fetus to grow larger than normal. Women who have had a large infant are more likely to develop GDM in subsequent pregnancies.
Choice B reason: Underweight before pregnancy is not a risk factor for GDM. In fact, being overweight or obese before pregnancy is a risk factor for GDM, as it increases insulin resistance and makes it harder for the body to use glucose effectively.
Choice C reason: A previous diagnosis of type 2 diabetes mellitus is not a risk factor for GDM. It is a contraindication for GDM, as it means that the woman already has diabetes before pregnancy. GDM is a condition that develops during pregnancy and usually resolves after delivery.
Choice D reason: Maternal age younger than 25 years is not a risk factor for GDM. In fact, being older than 25 years is a risk factor for GDM, as it increases the risk of insulin resistance and other metabolic changes that can affect glucose tolerance.
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