Which assessment finding indicates an adverse response to ...

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Which assessment finding indicates an adverse response to magnesium sulfate?
 
  a. Urine output of 30 mL/hr
  b. Respiratory rate of 11 breaths/min
  c. Hypoactive patellar reflex
  d. Blood pressure reading of 110/80 mm Hg

Question 2

A client who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the following assessments.
 
  The vaginal exam is deferred until the physician is in attendance. The client is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The client is then transferred to the antepartum unit for continued observation. Several hours later, the client complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The client is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring?
 
  a. Placental previa
  b. Active labor has started
  c. Placental abruption
  d. Hidden placental abruption

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Answer to Question 1

ANS: B
A respiratory rate less than 12 breaths/min indicates magnesium toxicity and requires immediate intervention. A urine output of 30 mL/hr is normal urinary output; a hypoactive patellar reflex and blood pressure reading of 110/80 mm Hg are normal findings in the client receiving magnesium sulfate.

Answer to Question 2

ANS: D
The client's signs and symptoms indicate that a hidden abruption is occurring. Fundal height has increased and there is an absence of fetal heart tones. This is a medical emergency and the physician should be contacted to come directly to the unit for intervention and imminent birth.