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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

Securing a clean diaper snugly across the newborn's penis might help manage minor bleeding but won't effectively address active oozing of bright red blood from a circumcision site.

Choice B rationale

Applying gentle pressure using a sterile dry gauze pad is the appropriate action to control bleeding. Applying direct pressure helps to stop the bleeding and allows for proper assessment of the wound.

Choice C rationale

Rinsing the newborn's penis with cool water might provide temporary relief but is not an effective method to control bleeding from a surgical site. It may also increase the risk of infection if not done sterilely.

Choice D rationale

Placing petroleum jelly on the bleeding site is typically done to prevent the diaper from sticking to the incision, but it is not sufficient to control active bleeding. .

Correct Answer is D

Explanation

Choice A rationale

Mongolian spots are common, benign skin markings that some newborns have, but they are not related to rubella exposure during pregnancy.

Choice B rationale

Jaundice is a common condition in newborns, characterized by a yellowing of the skin and eyes, usually due to an immature liver. It's not specifically linked to maternal rubella exposure.

Choice C rationale

Transient strabismus, or temporary misalignment of the eyes, can occur in newborns but is unrelated to rubella. It usually resolves on its own as the newborn's muscles develop.

Choice D rationale

Deafness is a significant risk associated with congenital rubella syndrome. Rubella can damage the developing auditory system in utero, leading to permanent hearing loss in the newborn.

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