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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Perineal hematoma is a complication that can occur after vaginal births, typically due to trauma or injury to the perineum during delivery. Wound dehiscence, UTIs, and DVTs are all possible complications associated with cesarean births. Wound dehiscence is a separation of the layers of the surgical incision, UTIs can occur due to catheterization during the surgery, and DVTs can occur due to immobility during the recovery period.
Correct Answer is C
Explanation
Infants of diabetic mothers (IDM) are at risk of hypoglycemia because they have been exposed to high levels of glucose in utero. The fetus responds to this high glucose level by producing high levels of insulin to regulate the glucose level. After delivery, the glucose supply from the mother is cut off and the infant's insulin levels remain high, leading to hypoglycemia.
Additionally, the infant's ability to produce glucose is immature and may not be sufficient to maintain normal blood glucose levels, especially if the infant is premature or small for gestational age. Therefore, IDM requires close monitoring of their blood glucose levels to prevent and treat hypoglycemia.
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