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
Explanation
Choice A rationale
Breastfeeding at least six times per day is too infrequent for a newborn. Newborns typically need to feed more frequently, approximately 8-12 times in 24 hours, to establish a good milk supply and ensure adequate nutrition.
Choice B rationale
Keeping a baby on a strict breastfeeding schedule is not recommended. Feeding should be on demand, based on the baby's hunger cues, to promote effective breastfeeding and milk production.
Choice C rationale
Feeding the baby for 30 minutes during each feeding is correct. This duration allows adequate time for the baby to receive both foremilk and hindmilk, which is essential for nutrition and satiety.
Choice D rationale
Holding the baby just below the level of the breast is incorrect. The baby should be held at breast level to facilitate proper latch and comfortable feeding for both mother and baby. .
Correct Answer is C
Explanation
Choice A rationale
Maternal age of 21 years is not considered a significant risk factor for gestational diabetes. Typically, advanced maternal age (35 years or older) is considered a risk factor due to changes in insulin resistance that occur with age.
Choice B rationale
A fasting blood glucose of 72 mg/dL is within the normal range and does not indicate a risk for gestational diabetes. Gestational diabetes is usually diagnosed with fasting blood glucose levels higher than 95 mg/dL.
Choice C rationale
Previous newborn weighing 4.8 kg is a significant risk factor for gestational diabetes. Having a macrosomic (large) baby in a previous pregnancy is linked with an increased risk of developing gestational diabetes in subsequent pregnancies.
Choice D rationale
A prepregnancy BMI of 23 is within the normal range (18.5-24.9) and does not increase the risk of gestational diabetes. Higher BMI levels, particularly above 25, are associated with an increased risk.