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 B
Explanation
Choice A rationale
Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.
Choice B rationale
Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.
Choice C rationale
Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.
Choice D rationale
Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.
Correct Answer is A
Explanation
Choice A rationale
Testing for GBS at around 36 weeks of gestation is standard practice to identify carriers and prevent neonatal GBS infections through intrapartum antibiotic prophylaxis if necessary.
Choice B rationale
Cesarean birth is not indicated solely based on a positive GBS status. The primary intervention is intrapartum antibiotic prophylaxis to reduce the risk of neonatal infection.
Choice C rationale
Routine antibiotic administration during the last weeks of pregnancy is not standard practice; antibiotics are given during labor if GBS is present to prevent transmission to the baby.
Choice D rationale
GBS infection does not cause hearing loss in newborns. The primary concern is neonatal sepsis, pneumonia, or meningitis, not hearing loss.