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 C
Explanation
Choice A rationale:
Cough. While a cough can be a side effect of inhaled steroids, it is not a significant concern compared to other potential risks. Long-term use of inhaled steroids can lead to slowed growth in children, making choice C the correct answer.
Choice B rationale:
Osteoporosis. Osteoporosis is a potential side effect of long-term use of inhaled steroids. These medications can affect bone density and increase the risk of osteoporosis, especially in individuals who are already at risk due to other factors such as age, gender, or family history.
Choice C rationale:
Slowed growth. Long-term use of inhaled steroids can lead to slowed growth in children. It's important for healthcare providers to monitor the growth of children with asthma who are taking these medications regularly. If slowed growth is observed, healthcare providers might consider adjusting the treatment plan.
Choice D rationale:
Cushing's syndrome. Cushing's syndrome is a rare but serious side effect of long-term steroid use. It is characterized by a collection of signs and symptoms caused by prolonged exposure to high levels of cortisol (a steroid hormone). While it's a potential risk, slowed growth is a more common concern in children taking long-term inhaled steroids.
Correct Answer is D
Explanation
Choice A rationale:
Leaving the infant in the room with the mother may not be appropriate, especially given the difficult delivery and the risk of complications, such as hypoglycemia.
Choice B rationale:
Taking the infant immediately to the nursery without monitoring vital signs and glucose levels could lead to missed signs of distress or hypoglycemia.
Choice C rationale:
Performing a gestational age assessment is important, but the immediate concern for this infant is the risk of hypoglycemia due to macrosomia (large birth weight). This choice does not address the immediate issue at hand.
Choice D rationale:
The correct answer. Macrosomic infants, especially those born after a difficult delivery, are at risk of hypoglycemia due to the excessive insulin production in response to high blood glucose levels. It is crucial to monitor the infant's blood glucose levels frequently and observe closely for signs of hypoglycemia, such as jitteriness, poor feeding, and lethargy.
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