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NurseDive Free Nursing Practice Question
A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
A. a sleepy, sedated affect.
A sleepy, sedated affect is not a concerning sign, as it is a common side effect of magnesium sulfate. Magnesium sulfate is a central nervous system depressant that can cause drowsiness, lethargy, and reduced alertness.
B. absent ankle clonus.
Absent ankle clonus is not a concerning sign, as it indicates a normal neuromuscular response. Ankle clonus is a rhythmic jerking of the foot when the ankle is dorsiflexed. It is a sign of hyperreflexia, which can occur in severe preeclampsia due to increased blood pressure and cerebral edema.
C. a respiratory rate of 10 breaths/min.
A respiratory rate of 10 breaths/min is a concerning sign, as it indicates respiratory depression. This is a serious complication of magnesium sulfate toxicity, which can lead to respiratory arrest and death. The nurse should monitor the woman's respiratory rate closely and report any signs of respiratory distress.
D. deep tendon reflexes of 2+.
Deep tendon reflexes of 2+ are not a concerning sign, as they indicate a normal neuromuscular response. Deep tendon reflexes are graded from 0 to 4, with 2 being the average. Magnesium sulfate can cause hyporeflexia or areflexia, which are signs of magnesium sulfate toxicity.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Midterm Proctored Exam 1. Take the full exam now
Full Explanation
Choice A reason: A sleepy, sedated affect is not a concerning sign, as it is a common side effect of magnesium sulfate. Magnesium sulfate is a central nervous system depressant that can cause drowsiness, lethargy, and reduced alertness.
Choice B reason: Absent ankle clonus is not a concerning sign, as it indicates a normal neuromuscular response. Ankle clonus is a rhythmic jerking of the foot when the ankle is dorsiflexed. It is a sign of hyperreflexia, which can occur in severe preeclampsia due to increased blood pressure and cerebral edema.
Choice C reason: A respiratory rate of 10 breaths/min is a concerning sign, as it indicates respiratory depression. This is a serious complication of magnesium sulfate toxicity, which can lead to respiratory arrest and death. The nurse should monitor the woman's respiratory rate closely and report any signs of respiratory distress.
Choice D reason: Deep tendon reflexes of 2+ are not a concerning sign, as they indicate a normal neuromuscular response. Deep tendon reflexes are graded from 0 to 4, with 2 being the average. Magnesium sulfate can cause hyporeflexia or areflexia, which are signs of magnesium sulfate toxicity.
Similar Questions
Which viral sexually transmitted infection is characterized by a primary infection followed by recurrent episodes?
A. Human immunodeficiency virus (HIV)
Human immunodeficiency virus (HIV) is a viral sexually transmitted infection that causes acquired immunodeficiency syndrome (AIDS). It is characterized by a progressive decline of the immune system, leading to opportunistic infections and cancers. It does not have recurrent episodes, but rather a chronic and incurable course.
B. Herpes simplex virus (HSV)-2
Herpes simplex virus (HSV)-2 is a viral sexually transmitted infection that causes genital herpes. It is characterized by a primary infection followed by recurrent episodes of painful blisters and ulcers in the genital area. The virus remains latent in the nerve cells and can reactivate periodically or in response to triggers such as stress, illness, or menstruation.
C. Human papillomavirus (HPV)
Human papillomavirus (HPV) is a viral sexually transmitted infection that causes genital warts and cervical cancer. It is characterized by a persistent infection that may or may not produce symptoms. It does not have recurrent episodes, but rather a variable and unpredictable course.
D. Cytomegalovirus (CMV)
Cytomegalovirus (CMV) is a viral sexually transmitted infection that causes mild or asymptomatic infections in healthy adults. It is characterized by a latent infection that can reactivate in immunocompromised individuals, causing serious complications such as retinitis, pneumonia, or encephalitis. It does not have recurrent episodes, but rather a dormant and opportunistic course.
Full Explanation
Choice A reason: Human immunodeficiency virus (HIV) is a viral sexually transmitted infection that causes acquired immunodeficiency syndrome (AIDS). It is characterized by a progressive decline of the immune system, leading to opportunistic infections and cancers. It does not have recurrent episodes, but rather a chronic and incurable course.
Choice B reason: Herpes simplex virus (HSV)-2 is a viral sexually transmitted infection that causes genital herpes. It is characterized by a primary infection followed by recurrent episodes of painful blisters and ulcers in the genital area. The virus remains latent in the nerve cells and can reactivate periodically or in response to triggers such as stress, illness, or menstruation.
Choice C reason: Human papillomavirus (HPV) is a viral sexually transmitted infection that causes genital warts and cervical cancer. It is characterized by a persistent infection that may or may not produce symptoms. It does not have recurrent episodes, but rather a variable and unpredictable course.
Choice D reason: Cytomegalovirus (CMV) is a viral sexually transmitted infection that causes mild or asymptomatic infections in healthy adults. It is characterized by a latent infection that can reactivate in immunocompromised individuals, causing serious complications such as retinitis, pneumonia, or encephalitis. It does not have recurrent episodes, but rather a dormant and opportunistic course.
When evaluating a patient for sexually transmitted infections (STIs), the nurse should be aware that the most common bacterial STI is:
A. syphilis.
Syphilis is a bacterial STI caused by Treponema pallidum. It is characterized by three stages: primary, secondary, and tertiary. It can cause serious complications such as neurosyphilis, cardiovascular syphilis, and congenital syphilis. However, it is not the most common bacterial STI.
B. candidiasis.
Candidiasis is a fungal infection caused by Candida albicans. It is not a STI, but rather an opportunistic infection that can affect the vagina, mouth, skin, or other mucous membranes. It can cause symptoms such as itching, burning, discharge, and inflammation.
C. gonorrhea.
Gonorrhea is a bacterial STI caused by Neisseria gonorrhoeae. It can infect the urethra, cervix, rectum, throat, or eyes. It can cause symptoms such as dysuria, discharge, pelvic pain, and bleeding. It can also lead to complications such as pelvic inflammatory disease, epididymitis, infertility, and disseminated gonococcal infection. However, it is not the most common bacterial STI.
D. chlamydia.
Chlamydia is a bacterial STI caused by Chlamydia trachomatis. It is the most common bacterial STI, affecting about 2.86 million people in the United States in 2018. It can infect the urethra, cervix, rectum, throat, or eyes. It can cause symptoms such as dysuria, discharge, pelvic pain, and bleeding. It can also lead to complications such as pelvic inflammatory disease, epididymitis, infertility, and ectopic pregnancy.
Full Explanation
Choice A reason: Syphilis is a bacterial STI caused by Treponema pallidum. It is characterized by three stages: primary, secondary, and tertiary. It can cause serious complications such as neurosyphilis, cardiovascular syphilis, and congenital syphilis. However, it is not the most common bacterial STI.
Choice B reason: Candidiasis is a fungal infection caused by Candida albicans. It is not a STI, but rather an opportunistic infection that can affect the vagina, mouth, skin, or other mucous membranes. It can cause symptoms such as itching, burning, discharge, and inflammation.
Choice C reason: Gonorrhea is a bacterial STI caused by Neisseria gonorrhoeae. It can infect the urethra, cervix, rectum, throat, or eyes. It can cause symptoms such as dysuria, discharge, pelvic pain, and bleeding. It can also lead to complications such as pelvic inflammatory disease, epididymitis, infertility, and disseminated gonococcal infection. However, it is not the most common bacterial STI.
Choice D reason: Chlamydia is a bacterial STI caused by Chlamydia trachomatis. It is the most common bacterial STI, affecting about 2.86 million people in the United States in 2018. It can infect the urethra, cervix, rectum, throat, or eyes. It can cause symptoms such as dysuria, discharge, pelvic pain, and bleeding. It can also lead to complications such as pelvic inflammatory disease, epididymitis, infertility, and ectopic pregnancy.
The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply)
A. Seizure activity and hypotension
Seizure activity and hypotension are not signs and symptoms of severe preeclampsia, but rather of eclampsia, which is a life-threatening complication of preeclampsia. Eclampsia is characterized by convulsions and coma, and it requires immediate treatment to prevent maternal and fetal death.
B. Platelet count of less than 100,000/mm3 and visual problems
Platelet count of less than 100,000/mm3 and visual problems are signs and symptoms of severe preeclampsia, as they indicate hematologic and neurologic complications. Severe preeclampsia can cause thrombocytopenia, which is a low platelet count that increases the risk of bleeding. It can also cause cerebral edema, which can impair the vision and cause blurred vision, spots, or flashes of light.
C. Ankle clonus and epigastric pain
Ankle clonus and epigastric pain are signs and symptoms of severe preeclampsia, as they indicate neuromuscular and hepatic complications. Severe preeclampsia can cause hyperreflexia, which is an exaggerated reflex response that can be elicited by dorsiflexing the ankle and observing rhythmic jerking of the foot. It can also cause liver damage, which can manifest as epigastric pain or right upper quadrant pain.
D. Decreased urinary output and irritability
Decreased urinary output and irritability are signs and symptoms of severe preeclampsia, as they indicate renal and central nervous system complications. Severe preeclampsia can cause oliguria, which is a reduced urine output of less than 500 mL in 24 hours. It can also cause increased intracranial pressure, which can affect the mood and behavior and cause irritability, anxiety, or confusion.
Full Explanation
Choice A reason: Seizure activity and hypotension are not signs and symptoms of severe preeclampsia, but rather of eclampsia, which is a life-threatening complication of preeclampsia. Eclampsia is characterized by convulsions and coma, and it requires immediate treatment to prevent maternal and fetal death.
Choice B reason: Platelet count of less than 100,000/mm3 and visual problems are signs and symptoms of severe preeclampsia, as they indicate hematologic and neurologic complications. Severe preeclampsia can cause thrombocytopenia, which is a low platelet count that increases the risk of bleeding. It can also cause cerebral edema, which can impair the vision and cause blurred vision, spots, or flashes of light.
Choice C reason: Ankle clonus and epigastric pain are signs and symptoms of severe preeclampsia, as they indicate neuromuscular and hepatic complications. Severe preeclampsia can cause hyperreflexia, which is an exaggerated reflex response that can be elicited by dorsiflexing the ankle and observing rhythmic jerking of the foot. It can also cause liver damage, which can manifest as epigastric pain or right upper quadrant pain.
Choice D reason: Decreased urinary output and irritability are signs and symptoms of severe preeclampsia, as they indicate renal and central nervous system complications. Severe preeclampsia can cause oliguria, which is a reduced urine output of less than 500 mL in 24 hours. It can also cause increased intracranial pressure, which can affect the mood and behavior and cause irritability, anxiety, or confusion.
Choice E reason: Transient headache and +1 proteinuria are not signs and symptoms of severe preeclampsia, but rather of mild preeclampsia, which is a less severe form of the condition. Mild preeclampsia is characterized by blood pressure of 140/90 mm Hg or higher, proteinuria of 1+ or higher, and mild edema. It does not cause severe complications or organ damage, but it can progress to severe preeclampsia if not treated.