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
After a forceps-assisted birth, the infant should be assessed for signs of trauma or injury, such as bruising, facial nerve injury, or skull fractures. This assessment should be done immediately after the birth to ensure prompt recognition and management of any issues.
Option A is incorrect because measuring the circumference of the infant's head can be done after the assessment for trauma has been completed and any issues have been addressed.
Option B is incorrect because applying a cold pack to the infant's scalp is not a standard nursing intervention after a forceps-assisted birth.
Option D is incorrect because prophylactic antibiotics are not routinely administered to infants after a forceps-assisted birth unless there is a specific indication, such as suspected infection.
Correct Answer is C
Explanation
Mom's blood type is A-negative, and baby's blood type is O-positive would place the neonate at risk for physiologic jaundice due to Rh incompatibility. When mom is Rh-negative and baby is Rh-positive, the mother's immune system can create antibodies that attack the baby's red blood cells, leading to the destruction of red blood cells and subsequent release of bilirubin, which can result in jaundice.
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