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?
Respiratory rate 10/min.
Urine output 160 mL in 4 hr.
Diaphoresis.
Nausea.
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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Correct Answer is D
Explanation
Choice A rationale
This statement is incorrect because after a cesarean birth, clients are usually started on clear liquids and then gradually progress to regular food as tolerated. Swallowing safety is related to anesthesia recovery, not cesarean birth recovery.
Choice B rationale
This statement is incorrect because the client does not need to stay flat on their back for 24 hours. Early ambulation is encouraged to prevent complications such as deep vein thrombosis and promote recovery.
Choice C rationale
This statement is incorrect because the urinary catheter is typically removed within 24 hours after surgery to reduce the risk of urinary tract infections and encourage normal bladder function.
Choice D rationale
This statement is correct because after a cesarean birth, the nurse will frequently assess the uterus for firmness and massage it as needed to prevent postpartum hemorrhage.
Correct Answer is D
Explanation
Choice A rationale
Remaining in the sitz bath for only 10 minutes might not provide enough relief for a postpartum client with an episiotomy and hemorrhoids. Extended periods in a sitz bath can help reduce pain and promote healing.
Choice B rationale
Using numbing spray before cleansing is helpful for pain management, but it is not as beneficial as other methods for reducing inflammation and promoting healing.
Choice C rationale
Placing a heat pack to the area several times a day can help with pain but might not be as effective as other options in reducing swelling and promoting healing of hemorrhoids and episiotomy sites.
Choice D rationale
Applying witch hazel pads after urination helps reduce swelling, provides soothing relief, and promotes healing for both hemorrhoids and episiotomy sites. Witch hazel has natural astringent properties that are beneficial for postpartum perineal care.