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 D
Explanation
The biophysical profile (BPP) would yield more detailed information about the fetus in this scenario. The BPP is a prenatal ultrasound evaluation that assesses fetal well-being by evaluating five biophysical variables: fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume, and fetal heart rate. The BPP is a more detailed assessment of fetal well-being compared to a nonstress test and can provide valuable information about the fetus's overall health and well-being, including any potential issues or difficulties.
MSAFP screening is a blood test that can detect certain fetal abnormalities, but it does not provide detailed information about fetal well-being.
Percutaneous umbilical blood sampling (PLBS) is an invasive test that is used to obtain a sample of fetal blood for testing in cases of suspected fetal anemia or other blood disorders. Ultrasound for fetal anomalies is a diagnostic tool used to detect structural abnormalities or defects in the fetus. While it can provide some information about fetal well-being, it is not as comprehensive as the BPP in evaluating fetal health and wellness.
Correct Answer is C
Explanation
Completing the Finnegan score is the most appropriate nursing intervention to help with the infant's hyperreflexia. The Finnegan score is a tool used to assess and monitor newborns for withdrawal symptoms related to maternal substance use during pregnancy, and hyperreflexia is one of the symptoms that can be scored using this tool. Based on the score, appropriate interventions can be implemented to address the infant's symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.