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 ["A","B","E","F"]
Explanation
A. Call the lactation consultant to visit the patient
Rationale: A lactation consultant is a specialized professional who can provide expert guidance on breastfeeding techniques and troubleshooting latching issues. They can offer personalized assistance and support to ensure proper latch and feeding.
B. Encourage and support the mother's desire/intention and include the partner in the conversation
Rationale: Providing emotional support and encouragement is crucial. Including the partner helps create a supportive environment for the mother and ensures that everyone is on the same page regarding breastfeeding goals and practices.
E. Check for audible swallowing and a comfortable (non-painful) suck
Rationale: Ensuring that the baby is swallowing and that the mother is not experiencing pain during feeding indicates that the latch may be correct. This helps confirm that the baby is feeding effectively and that the mother is comfortable.
Not Recommended:
C. Give the mother a bottle of formula to supplement
Rationale: Introducing formula supplementation is not necessary if the goal is exclusive breastfeeding. This step might undermine the mother's confidence or interfere with the baby's ability to latch properly.
D. Help the mother shove her nipple in the baby's mouth
Rationale: This approach can cause discomfort and may not address the underlying issue of improper latching. It is better to use techniques that encourage a natural and comfortable latch.
Note:
F. Assist with proper positioning and latch techniques"
Rationale:Proper positioning ensures the baby is comfortably aligned with their head in line with their body, and the baby is brought to the breast, not vice versa.
A good latch involves the baby opening their mouth wide to take in the nipple and a portion of the areola, which helps with milk transfer and reduces discomfort. Proper latch prevents pain and supports milk production.
Correct Answer is B
Explanation
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.