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A nurse is caring for a client who is receiving intravenous magnesium sulfate for preeclampsia.
Which assessment finding would alert the nurse to suspect magnesium toxicity?

A.

Rapid pulse.

B.

Tingling in toes.

C.

Cool skin temperature.

D.

Absent deep tendon reflexes.

Answer and Explanation

The Correct Answer is D

Choice A rationale

A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.

 

Choice B rationale

Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.

 

Choice C rationale

Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.

 

Choice D rationale

Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

A boggy and displaced fundus typically indicates bladder distention. Assisting the client to void can help relieve bladder distention, allowing the uterus to contract properly and

reducing the risk of postpartum hemorrhage.

Choice B rationale

Asking the client to rate her pain is important, but it does not address the immediate issue of a boggy, displaced fundus, which suggests bladder distention.

Choice C rationale

Encouraging the client to move to the left lateral position might help with blood flow and comfort but does not resolve the issue of a boggy fundus due to bladder distention.

Choice D rationale

Kegel exercises strengthen pelvic floor muscles but do not address the immediate concern of a boggy, displaced fundus caused by bladder distention.

Correct Answer is B

Explanation

Choice A rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the

head is turned and the opposite arm bending at the elbow, resembling a fencing position.

Choice B rationale

Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing

the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.

Choice C rationale

Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe

moving upward or toward the top surface of the foot and the other toes fanning out.

Choice D rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object

placed at the base of the toes. .

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