Magnesium Sulfate is being administered intravenously to a client for pregnancy-induced hypertension.
Which assessment finding should the nurse identify as a complication of this treatment?
Respiratory rate of 10 bpm.
Blood pressure of 148/94.
Deep tendon reflexes of +2.
Urine output of 70ml/hour.
The Correct Answer is A
Choice A rationale:
A respiratory rate of 10 bpm is significantly lower than the normal range for adults, which is typically 12-20 breaths per minute. This finding suggests respiratory depression, a potential complication of magnesium sulfate administration. Magnesium sulfate, when given intravenously, can lead to respiratory depression, hypotension, and loss of deep tendon reflexes. Monitoring respiratory rate is crucial to detect early signs of respiratory depression, allowing prompt intervention to prevent respiratory failure.
Choice B rationale:
A blood pressure of 148/94 mmHg is elevated and indicates hypertension. While hypertension is a known side effect of magnesium sulfate, a blood pressure reading alone is not specific enough to indicate a complication of treatment. It is essential to consider other vital signs and symptoms for a comprehensive assessment.
Choice C rationale:
Deep tendon reflexes of +2 are within the normal range and do not indicate a complication of magnesium sulfate administration. Hyperreflexia (exaggerated reflexes) is a sign of magnesium toxicity, but +2 reflexes are normal. Monitoring deep tendon reflexes is crucial, but the given value is within the normal range.
Choice D rationale:
An urine output of 70 ml/hour is within the normal range of urine output (30-60 ml/hour) for adults. While monitoring urine output is essential to assess renal function, this value does not indicate a complication of magnesium sulfate administration. Decreased urine output could suggest kidney injury, which is a potential complication of magnesium sulfate, but 70 ml/hour is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Nasal congestion and occasional epistaxis (nosebleeds) are common symptoms during pregnancy due to elevated levels of estrogen. Increased estrogen causes mucosal blood vessels to become engorged and more fragile, leading to nasal congestion and occasional nosebleeds. This is a normal respiratory change in pregnancy and not necessarily a cause for concern.
Choice B rationale:
While cardiovascular changes are common in pregnancy, nosebleeds alone are not indicative of abnormal cardiovascular changes unless they are accompanied by other symptoms. The given scenario does not provide enough information to support this choice.
Choice C rationale:
There is no evidence provided to suggest domestic violence (Choice C) as the cause of the woman's symptoms. Additionally, this choice lacks a physiological basis for the symptoms described.
Choice D rationale:
Intranasal cocaine use (Choice D) can indeed cause nasal congestion and frequent nosebleeds. However, the scenario does not provide any information to support this choice, and assuming drug use without evidence is not appropriate.
Correct Answer is A
Explanation
Choice A rationale:
The symptoms described by the baby's father, including confusion and having conversations with herself, are concerning and could indicate a severe mental health issue or a neurological problem. Urgent evaluation in an emergency room is necessary to rule out any acute medical or psychiatric condition that could be causing these symptoms. This is crucial for ensuring the safety and well-being of both the mother and the newborn.
Choice B rationale:
Bringing the wife to the office for medication is not appropriate in this situation without a proper evaluation. The symptoms described are severe and require immediate attention in an emergency room setting, where comprehensive assessments can be conducted.
Choice C rationale:
Outpatient care is not suitable for the described symptoms. The mother's confusion and hallucinations suggest a severe condition that requires urgent evaluation in a controlled environment like an emergency room. Outpatient care might be considered after the initial assessment and stabilization, but the immediate concern is the acute nature of the symptoms.
Choice D rationale:
Behavioral therapy is not appropriate for the described
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