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A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor. The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

A.

Nausea.

B.

Facial flushing.

C.

Urine output 40 mL/hr.

D.

Respiratory rate 10/min.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Nausea can be a side effect of magnesium sulfate, but it is not a specific indication of toxicity. Other symptoms are more directly indicative of magnesium sulfate overdose.

 

Choice B rationale

 

Facial flushing is a common side effect of magnesium sulfate but is not a sign of toxicity. It typically occurs at therapeutic levels and is not a reliable indicator of overdose.

 

Choice C rationale

 

Urine output of 40 mL/hr is within normal limits for an adult and does not indicate magnesium sulfate toxicity. However, significantly decreased urine output could be concerning.

 

Choice D rationale

 

Respiratory rate of 10/min is a critical sign of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a rate of 10 breaths per minute or less indicates that the patient may be experiencing toxic effects, necessitating immediate medical intervention.

 


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View Related questions

Correct Answer is A

Explanation

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.

Correct Answer is B

Explanation

Choice A rationale

Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.

Choice B rationale

Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.

Choice C rationale

Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.

Choice D rationale

Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.

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