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","B","C"]
Explanation
Choice A rationale:
Dried beans are excellent sources of plant-based protein and are suitable for a vegetarian diet. They are also rich in fiber, vitamins, and minerals.
Choice B rationale:
Seeds, such as chia seeds, flaxseeds, and pumpkin seeds, are good sources of protein, healthy fats, and various nutrients. They are suitable for vegetarians and can be incorporated into meals, salads, or smoothies.
Choice C rationale:
Peanut butter, made from ground peanuts, is a protein-rich food suitable for vegetarians. It can be spread on bread, added to smoothies, or used in various recipes.
Choice D rationale:
Bagels are not typically high in protein. They are primarily carbohydrate-based and do not serve as a significant source of protein for individuals following a vegetarian diet.
Choice E rationale:
Eggs are a good source of high-quality protein; however, they are not suitable for a strict vegetarian diet. Some vegetarians, known as ovo-vegetarians, include eggs in their diet, but strict vegetarians, known as vegans, avoid all animal products, including eggs.
Correct Answer is ["C","D","E"]
Explanation
The correct answer ischoices A, C, D, and E.
Choice A rationale:
A respiratory rate of 36 breaths/minute at rest is concerning in a pediatric client, as it may indicate respiratory distress or an underlying respiratory condition.
Choice B rationale:
An increasing appetite is generally a positive sign and not typically concerning unless accompanied by other symptoms.
Choice C rationale:
A temperature above 37.7° C (100° F) is concerning as it indicates fever, which could be a sign of infection or other medical conditions.
Choice D rationale:
New, frequent coughing is concerning as it may indicate respiratory infections, asthma, or other respiratory issues.
Choice E rationale:
Turning blue or bluer than normal (cyanosis) is a serious symptom indicating inadequate oxygenation and requires immediate medical attention.
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