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?
Nausea.
Facial flushing.
Urine output 40 mL/hr.
Respiratory rate 10/min.
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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Correct Answer is D
Explanation
Choice A rationale
Bumper pads can pose a suffocation risk to the newborn. The American Academy of Pediatrics advises against their use to promote a safe sleep environment.
Choice B rationale
Foam-wedge cushions are not recommended as they can increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS) by obstructing airflow.
Choice C rationale
Plastic covers can pose a suffocation hazard. Instead, using a fitted sheet is safer and reduces the risk of suffocation.
Choice D rationale
A well-fitting mattress reduces gaps between the mattress and crib sides, preventing entrapment, which helps reduce the risk of suffocation and injury.
Correct Answer is A
Explanation
Choice A rationale
Testing for GBS at around 36 weeks of gestation is standard practice to identify carriers and prevent neonatal GBS infections through intrapartum antibiotic prophylaxis if necessary.
Choice B rationale
Cesarean birth is not indicated solely based on a positive GBS status. The primary intervention is intrapartum antibiotic prophylaxis to reduce the risk of neonatal infection.
Choice C rationale
Routine antibiotic administration during the last weeks of pregnancy is not standard practice; antibiotics are given during labor if GBS is present to prevent transmission to the baby.
Choice D rationale
GBS infection does not cause hearing loss in newborns. The primary concern is neonatal sepsis, pneumonia, or meningitis, not hearing loss.