A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)
Evaluate fetal heart rate and contraction patterns.
Obtain prescription to repeat hepatic panel.
Monitor for evidence of seizure activity.
Check the urinary output in hourly urinometer.
Inspect the perineum for vaginal bleeding.
Correct Answer : A,B,C,D
Choice A rationale
Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.
Choice B rationale
Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.
Choice C rationale
Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.
Choice D rationale
Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.
Choice E rationale
Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Erythromycin ointment is administered to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae. Newborns are at risk for eye infections, which can lead to blindness if untreated. Erythromycin ointment provides effective prophylaxis.
Choice B rationale
Neomycin ointment is not indicated for prevention of ophthalmia neonatorum caused by Neisseria gonorrhoeae. It is primarily used for treating minor skin infections and not effective against eye infections in newborns.
Choice C rationale
Tetracaine eye drops are used as a local anesthetic for pain relief during minor eye procedures. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.
Choice D rationale
Latanoprost eye drops are used to treat glaucoma by reducing intraocular pressure. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.
Correct Answer is C
Explanation
Choice A rationale
Confirming Rh and Coombs status is essential for Rho(D) immunoglobulin administration, but it is not the immediate priority during acute bleeding as it does not directly address maternal or fetal distress.
Choice B rationale
Performing a sterile vaginal examination could potentially worsen bleeding if placental abruption or previa is present, making it a less safe option. The immediate concern is to assess fetal and maternal well-being.
Choice C rationale
Assessing the fetal heart rate and contraction pattern provides critical information on the fetus's condition and helps determine whether there is fetal distress, which is vital in deciding the urgency of interventions.
Choice D rationale
Determining fetal position using Leopold maneuvers is not a priority during acute bleeding episodes since it does not provide immediate information on fetal well-being or the cause of the bleeding.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.