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?
Rapid pulse.
Tingling in toes.
Cool skin temperature.
Absent deep tendon reflexes.
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 D
Explanation
Choice A rationale
Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to
ectopic pregnancy.
Choice B rationale
While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.
Choice C rationale
Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside
the uterus.
Choice D rationale
Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing
localized pain.
Correct Answer is A
Explanation
Choice A rationale
A newborn who is 26 hours post-delivery and has had no urine output needs immediate attention. Lack of urine output for over 24 hours may indicate dehydration or renal issues. Immediate medical evaluation is required to identify underlying conditions and prevent complications such as acute kidney injury or sepsis.
Choice B rationale
Acrocyanosis, characterized by blueish discoloration of the extremities, is common in newborns during the first 24-48 hours of life and usually resolves on its own. It occurs due to immature blood circulation and is generally not a cause for concern.
Choice C rationale
Failure to pass meconium within the first 24 hours can be a sign of conditions like Hirschsprung's disease or cystic fibrosis, but it is not as immediately concerning as anuria (no urine output). Monitoring and further evaluation are necessary, but it does not require urgent provider notification.
Choice D rationale
A blood glucose level of 50 mg/dL in a newborn is within the lower limit of normal. While it's important to monitor, it does not necessitate immediate provider notification unless it continues to drop or other symptoms arise.