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
Increasing the frequency of feedings from the affected nipple may aggravate nipple soreness, as it doesn't allow the area to recover and heal properly between feedings.
Choice B rationale
Exposing the affected nipple to the air between feedings can help it to dry and heal, reducing soreness. Air exposure can help prevent bacterial growth and keep the nipple area healthy.
Choice C rationale
Applying vitamin E oil to the affected nipple before each feeding is not recommended as it can make the nipple slippery, affecting the baby's latch, and it might not be safe if ingested by the baby.
Choice D rationale
Washing the affected nipple with soap and water before each feeding can strip the natural oils from the skin, leading to further dryness and irritation, which can increase soreness.
Correct Answer is A
Explanation
Choice A rationale
Assisting the client's partner to apply counterpressure to the sacrum can help alleviate the low-back pain associated with early labor by providing direct pressure to the area experiencing discomfort.
Choice B rationale
Maintaining the client on bed rest until active labor begins is not typically recommended, as mobility can help with the progression of labor and pain management.
Choice C rationale
Inserting an indwelling urinary catheter is not necessary for managing low-back pain in early labor and can increase the risk of infection and discomfort.
Choice D rationale
Teaching the client to hold their breath during contractions is not advisable, as it can lead to increased pain and decreased oxygenation for both the mother and baby. Breathing techniques are usually recommended to manage pain and ensure adequate oxygen delivery. .