Your patient is receiving magnesium sulfate for neuroprotection and preterm labor at 1 gram/hour. The most concerning vital sign below is:

Heart rate of 99

Respiratory rate of 9

BP of 99/69

Temperature of 99.9

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not the most concerning vital sign because a heart rate of 99 is within the normal range for an adult. The nurse should monitor the patient's heart rate and rhythm, but it is not a sign of magnesium toxicity or adverse effects.

Choice B reason: This is the most concerning vital sign because a respiratory rate of 9 is below the normal range for an adult and indicates respiratory depression, which is a sign of magnesium toxicity. The nurse should stop the infusion, notify the provider, and prepare to administer calcium gluconate as an antidotE.

Choice C reason: This is not the most concerning vital sign because a BP of 99/69 is within the normal range for an adult. The nurse should monitor the patient's blood pressure and fluid status, but it is not a sign of magnesium toxicity or adverse effects.

Choice D reason: This is not the most concerning vital sign because a temperature of 99.9 is within the normal range for an adult. The nurse should monitor the patient's temperature and infection signs, but it is not a sign of magnesium toxicity or adverse effects.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Massage a firm fundus. B. Determine whether the fundus is midlinE. C. Observe the lochia during palpation of fundus. D. Document fundal height. E. Administer terbutaline if the fundus is boggy.

Correct Answer is ["B"]

Explanation

Choice A: Massaging a firm fundus is not necessary, as it indicates that the uterus is contracting well and preventing excessive bleedinG. Massaging a firm fundus may cause discomfort and increase the risk of infection.

Choice B: Determining whether the fundus is midline is an important action, as it indicates that the uterus is in the correct position and not displaced by a full bladder or hematomA. A deviated fundus may cause uterine atony and hemorrhagE.

Choice C: Observing the lochia during palpation of fundus is an important action, as it indicates the amount and type of vaginal discharge after delivery. The nurse should assess the color, odor, consistency, and quantity of lochia and report any abnormal findings.

Choice D: Documenting fundal height is an important action, as it indicates the involution of the uterus after delivery. The nurse should measure the distance from the symphysis pubis to the top of the fundus in centimeters and compare it with the expected findings.

Choice E: Administering terbutaline if the fundus is boggy is not an appropriate action, as terbutaline is a tocolytic agent that relaxes the uterine muscles and may worsen the bleedinG. The nurse should massage a boggy fundus until it becomes firm and notify the provider.

View Question and Answer

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

Your patient is receiving magnesium sulfate for neuroprotection and preterm labor at 1 gram/hour. The most concerning vital sign below is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take FIRST?

Correct Answer is C

Explanation

A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply):

Correct Answer is ["B"]

Explanation

A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse make?

A nurse is caring for a client who is at 38 weeks of gestation and has a score of 10 on her biophysical profile. Which of the following actions should the nurse take?

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 100 beats/min. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagin

Benefits of immediate skin to skin contact include (Select all that apply):

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backachE. Which of the following factors is a contributing cause of difficult, prolonged labor?

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations? (Select onE.: