. nurse is assisting with the care of a client with PROM and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
Heart rate of 55/min
Urine output of 50 mL in 4 hr
Diminished deep-tendon reflexes
Respiratory rate of 16/min
The Correct Answer is D
A. Heart rate of 55/min. A heart rate of 55/min is bradycardia, which may indicate magnesium toxicity. This is a concerning sign and does not indicate safety to continue.
B. Urine output of 50 mL in 4 hr. A urine output of only 50 mL in 4 hours is too low (less than 30 mL/hr is concerning) and may indicate toxicity, since magnesium sulfate is excreted via the kidneys.
C. Diminished deep-tendon reflexes. Diminished deep-tendon reflexes (DTRs) may indicate magnesium toxicity. DTRs are monitored to assess for toxicity.
D. Respiratory rate of 16/min. A normal respiratory rate (12-20 breaths per minute) indicates that the magnesium sulfate has not caused respiratory depression, a sign of magnesium toxicity.
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Related Questions
Correct Answer is C
Explanation
A. Bloody show from the vagina: Bloody show is a normal sign during the second stage of labor, indicating that the cervix is dilating and the labor is progressing. It does not require immediate reporting.
B. Early decelerations in the FHR: Early decelerations are often a benign finding during labor, typically caused by head compression and do not usually indicate distress.
C. Uterine contraction lasting 2 minutes: A uterine contraction lasting 2 minutes is considered prolonged, and this can lead to decreased blood flow to the fetus, resulting in fetal distress. The provider should be notified.
D. Pelvic pressure with contractions: Pelvic pressure is a normal part of the second stage of labor as the fetus descends into the birth canal. This is an expected finding and does not require immediate reporting.
Correct Answer is A
Explanation
A. "The purpose of this medication is to boost fetal lung maturity." Betamethasone is a corticosteroid given to promote fetal lung maturity by stimulating surfactant production, especially in preterm labor.
B. "The purpose of this medication is to stop preterm labor contractions." Tocolytics, not corticosteroids, are used to stop preterm labor contractions. Betamethasone is not designed to halt contractions.
C. "The purpose of this medication is to halt cervical dilation." Betamethasone does not affect cervical dilation. Its role is to support fetal lung development.
D. "The purpose of this medication is to increase the fetal heart rate." Betamethasone does not directly influence fetal heart rate. Its primary use is to mature fetal lungs in anticipation of early birth.
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