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The client at 25 weeks gestation in preterm labor has developed pre-eclampsia.
After receiving Nifedipine to stop her contractions, she is started on magnesium sulfate to control her pre-eclampsia.
When assessing the client, which findings by the nurse indicate that the client is experiencing an adverse effect from the magnesium sulfate? (Select all that apply).

Respiratory rate of 8 breaths per minute.

Blood pressure of 150/90 mmHg.

Lung crackles.

Increase in fetal heart rate.

Deep tendon reflexes.

Confusion.

Urine output of 30 mL in 2 hours.

Answer and Explanation

Correct Answer : A,F,G

Choice A rationale

Respiratory rate of 8 breaths per minute indicates respiratory depression, a serious adverse effect of magnesium sulfate toxicity. Magnesium sulfate can depress neuromuscular transmission, leading to decreased respiratory effort and rate.

Choice B rationale

Blood pressure of 150/90 mmHg is not indicative of magnesium sulfate toxicity. Elevated blood pressure is a symptom of pre-eclampsia and not directly related to the adverse effects of magnesium sulfate. Therefore, it does not indicate toxicity.

Choice C rationale

Lung crackles are typically associated with fluid overload or heart failure rather than magnesium sulfate toxicity. While it is a serious condition, it is not specifically an adverse effect of magnesium sulfate.

Choice D rationale

Increase in fetal heart rate is not a common adverse effect of magnesium sulfate. Fetal heart rate changes are more commonly related to the underlying maternal condition or other medications used in pregnancy rather than magnesium sulfate.

Choice E rationale

Deep tendon reflexes would typically be decreased or absent in magnesium sulfate toxicity. Therefore, presence of deep tendon reflexes would not indicate an adverse effect of magnesium sulfate.

Choice F rationale

Confusion can occur due to central nervous system depression caused by high levels of magnesium sulfate. This is a significant adverse effect indicating possible toxicity.

Choice G rationale

Urine output of 30 mL in 2 hours suggests oliguria, which can be a sign of magnesium sulfate toxicity as the drug is excreted through the kidneys. Reduced urine output can indicate the kidneys are not clearing the drug efficiently, leading to toxicity.

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Correct Answer is C

Explanation

Choice A rationale

Left occiput anterior (LOA) describes the occiput facing toward the front left of the maternal pelvis, not the back. LOA typically does not cause back labor.

Choice B rationale

Right occiput posterior (ROP) describes the occiput facing toward the back right of the maternal pelvis, not the left. ROP can cause back labor but is not aligned with the described position.

Choice C rationale

Left occiput posterior (LOP) means the occiput is facing the back left of the maternal pelvis, aligning with the description and commonly causing back labor pain.

Choice D rationale

Right occiput anterior (ROA) describes the occiput facing the front right of the maternal pelvis, not the left. ROA is not associated with increased back labor pain. .

A. Pain B. Vaginal discharge C. Temperature

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"}}

Explanation

A. Pain: Consistent with both urinary tract infection (UTI) and preterm labor. UTI can cause dysuria and pelvic pain, while preterm labor can present with lower abdominal pain or cramping.

B. Vaginal discharge: Consistent with both urinary tract infection and preterm labor. UTI can cause unusual vaginal discharge due to infection, while increased or unusual discharge can be a sign of preterm labor.

C. Temperature: Consistent with urinary tract infection. Fever is a common symptom of UTI due to infection. Preterm labor usually does not involve a fever unless there is an infection present.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Using Leopold's Maneuvers, the fetus is found to be with its occiput facing toward the left maternal spine.The mother is complaining of increased back labor pain.The nurse knows that the fetus is in which position?

Correct Answer is C

Explanation

A nurse reviews assessment findings. For each assessment finding, specify if the finding is consistent with a urinary tract infection or preterm labor. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"}}

Explanation

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