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 D
Explanation
Choice A rationale:
Bronchoscopy is not the essential test for diagnosing cystic fibrosis. Bronchoscopy is a procedure that allows the healthcare provider to visualize the airways and lungs but is not the primary test for cystic fibrosis diagnosis. Cystic fibrosis is primarily diagnosed through genetic testing and sweat chloride testing.
Choice B rationale:
Serum calcium levels are not specific to cystic fibrosis diagnosis. Serum calcium levels are typically used to assess calcium balance in the body and are not directly related to cystic fibrosis diagnosis.
Choice C rationale:
Urine creatinine levels are not specific to cystic fibrosis diagnosis. Urine creatinine levels are often used to assess kidney function and muscle breakdown but are not diagnostic for cystic fibrosis.
Choice D rationale:
Sweat chloride test is essential in establishing the diagnosis of cystic fibrosis. Cystic fibrosis is characterized by the abnormal transport of chloride across cell membranes, leading to salty sweat. The sweat chloride test measures the amount of chloride in the sweat and is a key diagnostic test for cystic fibrosis. Values above a certain threshold (typically 60 mmol/L) are suggestive of cystic fibrosis.
Correct Answer is A
Explanation
Choice A rationale:
It is a belief common at this age. Rationale: The child's belief that she has cancer because God is punishing her for "being bad" and her fear of going to hell if she dies is consistent with magical thinking, which is common in children around the age of 8. Children at this age often have difficulty understanding cause and effect relationships, leading to magical or illogical thinking patterns. It is essential for the nurse to recognize this developmental aspect and respond empathetically and supportively.
Choice B rationale:
Choice C rationale:
The belief is suggestive of excessive family pressure. Rationale: There is no evidence in the scenario to suggest that the child's belief is related to family pressure. The child's statements are more consistent with age-appropriate magical thinking and fear related to concepts of punishment and the afterlife.
Choice D rationale:
The statement suggests a failed attempt to develop a conscience. Rationale: The child's belief does not indicate a failed attempt to develop a conscience. Instead, it reflects a typical developmental stage where children often have magical thoughts and fears. This stage is temporary and part of normal cognitive development.
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