The nurse is aware that which of the following magnesium sulfate levels should be reported to the MD and is most likely to result in toxicity?
61 mEq/L.
70 mEq/L.
29 mEq/L.
45 mEq/L.
The Correct Answer is B
Choice A rationale
A magnesium sulfate level of 61 mEq/L is high and may cause toxicity, but the most critical level is higher.
Choice B rationale
A magnesium sulfate level of 70 mEq/L is extremely high and most likely to result in toxicity, including respiratory and cardiac complications.
Choice C rationale
A magnesium sulfate level of 29 mEq/L is elevated but not necessarily indicative of toxicity.
Choice D rationale
A magnesium sulfate level of 45 mEq/L is also high but less critical compared to 70 mEq/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Maternal fever due to chorioamnionitis would show maternal signs of infection and not directly indicate fetal heart rate changes typical of umbilical cord prolapse.
Choice B rationale
Compression due to lack of amniotic fluid (oligohydramnios) typically shows variable decelerations on the fetal monitoring strip but is not urgent without other symptoms.
Choice C rationale
Umbilical cord prolapse is an urgent condition where the umbilical cord slips ahead of the fetus and can be indicated by sudden severe variable decelerations on the fetal monitor strip, requiring immediate intervention.
Choice D rationale
Progression of the fetal head through the vaginal canal shows a gradual change in the fetal heart rate and not the sudden pattern seen with cord prolapse.
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.
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