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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

Disabling the driver-side airbags is not advisable as airbags provide crucial protection in the event of a collision. Proper seating position is a safer alternative.

Choice B rationale

Moving the seat as far away as possible from the steering wheel reduces the risk of injury from airbag deployment and allows ample space for the growing abdomen, providing better safety for both mother and baby.

Choice C rationale

Wearing the lap belt high across the abdomen is incorrect and dangerous as it can cause injury to the fetus. The belt should be low across the hips.

Choice D rationale

Placing the shoulder harness across the gravid uterus is incorrect. The harness should go between the breasts and to the side of the belly, not across it, to avoid compression injuries in the event of a crash.

Correct Answer is B

Explanation

Choice A rationale

Ensuring the client has a full bladder before the procedure is incorrect. A full bladder can cause discomfort during the pelvic examination and may obscure the pelvic organs, making the examination more challenging for the provider.

Choice B rationale

Instructing the client to bear down when the speculum is inserted is correct. Bearing down helps relax the pelvic muscles, making it easier to insert the speculum and perform the examination with minimal discomfort.

Choice C rationale

Encouraging the client to take rapid, shallow breaths during the procedure is incorrect. This can increase anxiety and tension in the pelvic muscles, making the examination more uncomfortable.

Choice D rationale

Applying povidone-iodine to the provider's fingers prior to bimanual examination is incorrect. The standard procedure involves using gloves and lubricant to prevent infection and ensure patient comfort, not povidone-iodine.

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