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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

Each feeding should last between 20 and 30 minutes to ensure the baby gets enough nutrition and to facilitate bonding time.

Choice B rationale

Prepared formula should be used within 24 hours if stored in the refrigerator, not 5 days, to prevent bacterial growth and ensure the baby's safety.

Choice C rationale

Formula left at room temperature should not be refrigerated for reuse; it can develop bacteria that may harm the baby.

Choice D rationale

It is recommended to burp the baby multiple times during feeding to release swallowed air and prevent discomfort or spitting up.

Correct Answer is A

Explanation

Choice A rationale

Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.

Choice C rationale

Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.

Choice D rationale

A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.

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