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.

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Correct Answer is B

Explanation

A. This is a cephalhematoma, which will resolve on its own in 3 to 5 days. B. This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin. C. This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. D. This is a Mongolian spot, which is found on many newborns.

Correct Answer is C

Explanation

Choice A reason: This is not the correct response because a cephalhematoma is a collection of blood under the periosteum of the skull that does not cross the suture linE. It usually takes several weeks to months to resolvE.

Choice B reason: This is not the correct response because erythema toxicum is a benign rash that appears as red macules or papules with white or yellow centers. It does not cause swelling on the head and can occur anywhere on the body.

Choice C reason: This is the correct response because a caput succedaneum is a collection of fluid under the scalp that crosses the suture linE. It is caused by pressure from the vacuum extractor or the birth canal. It usually resolves within a few days.

Choice D reason: This is not the correct response because a Mongolian spot is a bluish-gray or brown patch of pigmentation that is usually found on the lower back or buttocks. It does not cause swelling on the head and is not related to the mode of delivery.

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

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