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
The correct answer is: B. 3-1-1-0-3.
Choice A reason:
This option suggests the woman has been pregnant four times, which is incorrect. She has had three pregnancies: one set of twins (counted as one pregnancy) and two singletons.
Choice B reason:
This is the correct option. The woman has had three pregnancies (Gravida = 3), one full-term delivery (Term = 1), one preterm delivery (the twins, Preterm = 1), no abortions (Abortions = 0), and three living children (Living = 3).
Choice C reason:
This option incorrectly suggests two preterm deliveries and one abortion, neither of which is indicated in the woman's history.
Choice D reason:
This option incorrectly suggests two preterm deliveries (the twins are counted as one preterm delivery) and does not accurately reflect the woman's history.
GTPAL stands for Gravida (total number of pregnancies), Term births (deliveries after 37 weeks), Preterm births (deliveries between 20-36 weeks), Abortions (losses before 20 weeks), and Living children. Normal ranges: Term (≥37 weeks), Preterm (20-36 weeks)
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Urinary frequency is a common symptom of pregnancy, especially in the first and third trimesters, due to the increased pressure of the uterus on the bladder. It is not a sign of complication and does not need to be reported immediately.
Choice B reason: Rupture of membranes is the breaking of the amniotic sac, which can occur spontaneously or artificially before or during labor. It is a sign of impending delivery and can increase the risk of infection. It should be reported immediately to the health care provider.
Choice C reason: Heartburn accompanied by severe headache can indicate preeclampsia, a serious condition characterized by high blood pressure and proteinuria in pregnancy. It can lead to eclampsia, which is a life-threatening seizure disorder. It should be reported immediately to the health care provider.
Choice D reason: Decreased libido is a normal change in pregnancy, due to hormonal fluctuations, physical discomfort, and emotional stress. It is not a sign of complication and does not need to be reported immediately.
Choice E reason: Vaginal bleeding can indicate various complications in pregnancy, such as placenta previa, placental abruption, or miscarriage. It can pose a threat to the mother and the fetus. It should be reported immediately to the health care provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today