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 ["C","E"]
Explanation
Choice A rationale
Douching is generally not recommended, especially during pregnancy, because it can disrupt the natural balance of bacteria in the vagina, potentially leading to infections or other complications.
Choice B rationale
Avoiding urination at bedtime is not advisable, as holding in urine can increase the risk of urinary tract infections (UTIs). Frequent urination is a good practice to help prevent and manage UTIs.
Choice C rationale
Wearing cotton-crotch underwear is recommended because cotton is breathable and helps to keep the genital area dry, reducing the risk of infections and irritation.
Choice D rationale
Eliminating yogurt products from the diet is not necessary; in fact, yogurt contains probiotics that can be beneficial for maintaining a healthy balance of bacteria in the gut and vaginal area.
Choice E rationale
Refraining from taking bubble baths is advised, as the chemicals in bubble bath products can irritate the urethra and increase the risk of UTIs.
Correct Answer is C
Explanation
Choice A rationale
Starting each feeding with the same breast can lead to engorgement and decreased milk supply in the other breast.
Choice B rationale
Exclusive breastfeeding is recommended for the first six months. Providing a formula supplement can interfere with milk supply and breastfeeding success.
Choice C rationale
Allowing the newborn to empty the first breast ensures they receive hindmilk, which is richer in fat and essential for growth.
Choice D rationale
Newborns do not need additional water as breast milk or formula provides all necessary hydration.