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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The first stage of labor, transition phase, is characterized by rapid cervical dilation from 7 cm to 10 cm, intense contractions, and strong desire to push. This client's cervix is only 3 cm dilated, indicating that she is not in the transition phase.
Choice B rationale
The second stage of labor, active phase, is the period from full cervical dilation to the birth of the baby. This stage involves active pushing and the descent of the baby through the birth canal. This client's cervix is not fully dilated, so she cannot be in the second stage.
Choice C rationale
The second stage of labor, latent phase, does not exist. The latent phase is part of the first stage of labor, not the second stage. This choice is incorrect because it misrepresents the stages of labor.
Choice D rationale
The first stage of labor, latent phase, is characterized by regular contractions, cervical effacement, and dilation up to 4 cm. This client's cervix is 80% effaced and 3 cm dilated, indicating that she is in the latent phase of the first stage of labor.
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. .
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