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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 A

Explanation

Choice A rationale

This finding indicates fetal distress. Recurrent variable decelerations in the fetal heart rate (FHR) can be a sign of umbilical cord compression, which can compromise fetal oxygenation.

Choice B rationale

Uterine contractions every 6 minutes are within the normal range for the latent phase of labor and do not indicate fetal risk.

Choice C rationale

Moderate variability of the FHR is a reassuring sign and suggests that the fetus is well-oxygenated and neurologically intact.

Choice D rationale

Uterine contractions lasting 30 to 45 seconds are typical for the latent phase of labor and do not indicate fetal distress.

Correct Answer is B

Explanation

Choice A rationale

"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.

Choice B rationale

"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.

Choice C rationale

"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.

Choice D rationale

"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.

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