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 B
Explanation
Bedrest is no longer recommended as it does not improve outcomes and may increase the risk of complications such as thromboembolism and pneumonia. Instead, patients with a placenta previa should be advised to avoid activities that may increase pelvic pressure, such as sexual intercourse, heavy lifting, and strenuous exercise. The other options are appropriate instructions to include in the patient's discharge plan.
Correct Answer is A
Explanation
In the case of a prolapsed umbilical cord, the first priority intervention is to relieve pressure on the cord. Placing the woman in the knee-chest position or Trendelenburg position with the hips elevated is the best way to achieve this. This position helps to reduce the compression of the cord and improve fetal oxygenation.
Option B is incorrect because while oxygen may be necessary, relieving pressure on the cord is the priority.
Option C is incorrect because a vaginal birth should not proceed with a prolapsed umbilical cord, as it can cause cord compression and fetal distress.
Option D is incorrect because covering the cord in sterile gauze soaked in saline is not a priority intervention and may not be effective in relieving pressure on the cord.
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