A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?
Assess maternal blood glucose.
Discontinue the magnesium infusion.
Prepare for an emergency cesarean birth.
Place the client in Trendelenburg position.
The Correct Answer is B
Choice A reason:
Assessing maternal blood glucose is important in various clinical scenarios, such as managing diabetes during pregnancy. However, it is not directly related to the immediate issue of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min is a critical sign that requires immediate intervention to prevent further complications.
Choice B reason:
Discontinuing the magnesium infusion is the priority intervention. Magnesium sulfate toxicity can lead to severe respiratory depression, hypotension, and loss of deep tendon reflexes. A respiratory rate of 10/min indicates significant respiratory depression, which can be life-threatening. Stopping the infusion immediately helps to prevent further accumulation of magnesium in the body and allows for the administration of the antidote, calcium gluconate, if necessary.
Choice C reason:
Preparing for an emergency cesarean birth is a critical intervention in cases of fetal distress or other obstetric emergencies. However, in this scenario, the immediate concern is the client’s respiratory depression due to magnesium sulfate toxicity. Addressing the respiratory issue takes precedence to stabilize the client before considering any surgical interventions.
Choice D reason:
Placing the client in Trendelenburg position is typically used to treat hypotension or shock by promoting venous return to the heart. While it can be beneficial in certain situations, it does not address the primary issue of respiratory depression caused by magnesium sulfate toxicity. The priority is to discontinue the magnesium infusion and manage the respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Notifying the client’s provider is not immediately necessary in this scenario. The presence of lochia rubra and small clots is typical in the early postpartum period, especially when the fundus is firm and midline, indicating that the uterus is contracting well.
Choice B Reason:
Increasing the frequency of fundal massage is not required when the fundus is already firm and midline. Fundal massage is typically indicated if the uterus is boggy or not contracting adequately, which is not the case here
Choice C Reason:
Encouraging the client to empty her bladder is a good practice to prevent bladder distention, which can interfere with uterine contraction. However, it is not the priority action given the current findings.
Choice D Reason:
Documenting the findings and continuing to monitor the client is the most appropriate action. The observations are within normal limits for a client who is 1 hour postpartum. Continuous monitoring ensures that any changes in the client’s condition can be promptly addressed.
Correct Answer is B
Explanation
Choice A Reason:
The presence of 3+ protein in the urine is consistent with preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, indicating kidney involvement and damage. High levels of protein in the urine are a common finding in patients with preeclampsia.
Choice B Reason:
Deep tendon reflexes of 1+ are inconsistent with preeclampsia. Preeclampsia often causes hyperreflexia, which means increased reflex responses. Typically, patients with preeclampsia exhibit brisk reflexes (3+ or 4+), which can be a sign of central nervous system irritability and an increased risk of seizures.
Choice C Reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. Preeclampsia is characterized by high blood pressure, defined as systolic blood pressure of 140 mm Hg or higher, or diastolic blood pressure of 90 mm Hg or higher, measured on two occasions at least four hours apart.
Choice D Reason:
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the lower extremities and sacral area, is a common symptom of preeclampsia due to increased capillary permeability and fluid retention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today