A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

potassium chloride

ferrous sulfate

calcium carbonate

calcium gluconate

Answer and Explanation

The Correct Answer is D

A. Potassium chloride is not used in the treatment of magnesium sulfate toxicity. Potassium chloride is typically used to correct low potassium levels, but it is not directly related to managing magnesium sulfate toxicity.

B. Ferrous sulfate is an iron supplement, typically used to treat or prevent iron deficiency anemia, and does not play a role in managing magnesium sulfate toxicity.

C. Calcium carbonate is an antacid and is not used to counteract magnesium sulfate toxicity.

D. Calcium gluconate is the correct choice. Magnesium sulfate is used in severe preeclampsia to prevent seizures, but it can cause toxicity, leading to respiratory depression, loss of deep tendon reflexes, or even cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available to reverse these effects if necessary.

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Correct Answer is B

Explanation

A. Stepping reflex is elicited by holding the newborn upright with feet touching a flat surface; the baby will make stepping movements.

B. Babinski reflex is correct. This reflex is elicited by stroking the lateral sole of the foot from the heel to the ball of the foot. A positive Babinski response in newborns is dorsiflexion of the big toe and fanning of the other toes — a normal finding up to about 12 months of age.

C. Tonic neck reflex (also called the “fencing” reflex) is seen when the newborn's head is turned to one side — the arm on that side extends while the opposite arm bends.

D. Plantar grasp is elicited by pressing a finger against the sole of the foot near the toes; the newborn will respond by curling the toes downward.

A. Request the client to empty her bladder B. Follow PRN order to insert a straight urinary catheterization C. Start an IV and add 20 units Pitocin D. Massage fundus until it descends below the level on umbilicus.

Correct Answer is A

Explanation

A. Request the client to empty her bladder is the correct action. A fundus that is firm but deviated to the left and higher than expected (U+1) suggests that the bladder is full. A full bladder can displace the uterus, causing it to become misaligned and elevated. Asking the client to empty her bladder is often the first step to address this situation before proceeding with further assessment or intervention.

B. Follow PRN order to insert a straight urinary catheterization might be appropriate if the client is unable to empty her bladder voluntarily, but it is typically a last resort. Before resorting to catheterization, encourage the client to try to void first.

C. Start an IV and add 20 units Pitocin would be indicated if there were signs of uterine atony or hemorrhage. However, in this case, the issue seems related to bladder distention rather than uterine atony, so starting Pitocin is not the appropriate immediate response.

D. Massage fundus until it descends below the level of the umbilicus would be done if the fundus were boggy or soft, indicating uterine atony. However, in this case, the fundus is described as firm, so massaging is not necessary. The priority is addressing the bladder distention.

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A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?

Correct Answer is B

Explanation

During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus is firm, but the level has changed from U-1 to U+1 and deviated to the left. Which action would be appropriate before continuing the assessment?

Correct Answer is A

Explanation

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