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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct Answer is B
Explanation
Choice A: Applying warm, moist soaks to the client's lower legs is not an effective intervention, as it can increase the swelling and the discomfort of the legs and interfere with the healing of the incision. The nurse should avoid applying heat to the legs and use compression stockings or pneumatic devices insteaD.
Choice B: Having the client ambulate frequently in the hallway is an effective intervention, as it can improve the blood circulation and prevent the formation of blood clots in the legs. The nurse should encourage the client to ambulate as soon as possible after the surgery and assist the client with the first ambulation.
Choice C: Keeping the client on bed rest is not an appropriate intervention, as it can increase the stasis and the coagulation of the blood and increase the risk of thrombophlebitis. The nurse should avoid prolonged bed rest and promote early mobilization of the client.
Choice D: Placing pillows under the client's knees while she is resting in bed is not an appropriate intervention, as it can impair the venous return and increase the pressure and the inflammation of the legs. The nurse should avoid placing anything under the client's knees and keep the legs slightly elevated and in a straight position.
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