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
An apical pulse of 66/min is within the normal range and not indicative of postpartum hemorrhage, which would typically cause an elevated heart rate due to blood loss.
Choice B rationale
A temperature of 38.3°C (101°F) could indicate infection or inflammation but is not a direct sign of postpartum hemorrhage, which primarily involves significant blood loss.
Choice C rationale
Blood pressure of 156/80 mm Hg is elevated but not directly indicative of postpartum hemorrhage, which would typically result in a drop in blood pressure due to loss of blood volume.
Choice D rationale
A respiratory rate of 32/min is significantly elevated and can be a compensatory response to hypovolemia from postpartum hemorrhage. This response occurs as the body tries to increase oxygen delivery due to blood loss.
Correct Answer is A
Explanation
Choice A rationale
Penicillin is the recommended prophylactic treatment for a client at 38 weeks of gestation with a positive group B streptococcus B-hemolytic screening. It is highly effective in preventing the transmission of group B strep from mother to baby during labor and delivery. Administering Penicillin reduces the risk of neonatal sepsis, pneumonia, and meningitis caused by group B strep.
Choice B rationale
Cefazolin is an alternative antibiotic for clients allergic to penicillin. It is less preferred compared to penicillin due to its broader spectrum of activity and potential for resistance. Cefazolin can be used if the client has a non-severe penicillin allergy.
Choice C rationale
Erythromycin is not recommended for group B strep prophylaxis during labor due to its lower efficacy compared to penicillin and cefazolin. It is less effective in preventing neonatal group B strep infections and is used less frequently.
Choice D rationale
Vancomycin is used for clients with a severe penicillin allergy or for those with resistant strains of group B strep. It is a last-resort antibiotic due to its potent effect and potential side effects. It is only used when absolutely necessary.