. 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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 C
Explanation
A. Apply palms of both hands to one side of the uterus: This step helps identify the fetal position (whether the baby is facing left or right), not the fetal lie.
B. Stand facing the client's feet with fingertips outlining cephalic prominence. This maneuver helps determine fetal engagement, not fetal lie.
C. Palpate the fundus of the uterus. The fetal lie refers to whether the fetus is positioned longitudinally or transversely, and this is assessed by palpating the fundus to feel which part of the fetus is located there (e.g., head or buttocks).
D. Perform deep palpation of the uterus. Deep palpation helps identify the presenting part (what part of the fetus is entering the pelvis), not fetal lie.
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