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A nurse is assisting with the care of a client who has a prescription for magnesium sulfate. Which of the following adverse effects should the nurse report to the provider?

A.

Respiratory rate 10/min.

B.

Urine output 160 mL in 4 hr.

C.

Diaphoresis.

D.

Nausea.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Respiratory rate of 10/min is a critical adverse effect, indicating potential respiratory depression due to magnesium sulfate, a serious and life-threatening condition requiring immediate intervention.

 

Choice B rationale

 

Urine output of 160 mL in 4 hours is lower than expected but not immediately life-threatening. It needs monitoring but is not as critical as respiratory rate.

 

Choice C rationale

 

Diaphoresis, or excessive sweating, can be a side effect of magnesium sulfate but is not life-threatening. It warrants attention but does not require immediate reporting.

 

Choice D rationale

 

Nausea is a common, less severe side effect of magnesium sulfate that does not indicate an urgent situation.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.

Choice B rationale

Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.

Choice C rationale

Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.

Choice D rationale

Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.

Correct Answer is A

Explanation

Choice A rationale

A single crease in the palm, known as a simian crease, is a common characteristic seen in infants with trisomy 21 (Down syndrome) due to the unique hand structure associated with this condition.

Choice B rationale

A notch in the lip, such as a cleft lip, is not commonly associated with trisomy 21 and is more typically related to other genetic conditions or environmental factors during development.

Choice C rationale

An inversion of the foot, such as clubfoot, is not a specific characteristic of trisomy 21. This condition is more often seen in other congenital anomalies not related to Down syndrome.

Choice D rationale

Extra digits on the hand, or polydactyly, is not commonly associated with trisomy 21 but can be seen in other genetic disorders. Trisomy 21 has more specific physical features like the simian crease.

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