The nurse is caring for a 30-week gestation client who was loaded on a magnesium sulfate infusion one hour ago for preterm labor. Which of the following assessment findings would warrant the infusion to be discontinued immediately?
Blood pressure of 138/88.
Urinary output of 40 ml/hr.
Respiratory rate of 10 breaths/minute.
Patellar reflex of +2.
The Correct Answer is C
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation

Correct Answer is B
Explanation
The information that the nurse should emphasize in the discharge teaching for a pregnant woman who has undergone a cervical cerclage due to an incompetent cervix is that the presence of any contractions, rupture of membranes (ROM), or severe perineal pressure should be reported to her healthcare provider immediately. This is because these symptoms could indicate cervical dilation or premature labor, which can lead to pregnancy loss or other complications.
Reporting any vaginal discharge is important, but it is not the most critical symptom to monitor for after cervical cerclage placement. Vaginal discharge is common after cervical cerclage and can occur for several weeks without posing a significant risk to the pregnancy.
A cesarean birth may or may not be necessary depending on the patient's individual circumstances and the course of the pregnancy. It is not a given that all women with cervical cerclage require a cesarean delivery.
While some activity restrictions may be necessary after cervical cerclage placement, it is not necessary for the patient to arrange for care at home. Many women are able to manage their daily activities with appropriate precautions and guidance from their healthcare provider.

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