A client with severe preeclampsia is receiving magnesium sulfate. The nurse notes the following vital signs: blood pressure 146/90 mm Hg at 1220 and 141/86 mm Hg at 1230.
What is the most appropriate action for the nurse to take?
Discontinue the magnesium sulfate infusion as the blood pressure has decreased.
Decrease the dosage of the magnesium sulfate.
Continue to monitor the client's vital signs as the blood pressure is trending in the right direction.
Increase the frequency of blood pressure checks.
The Correct Answer is C
Choice A rationale
The primary goal of magnesium sulfate therapy in preeclampsia is seizure prophylaxis, not solely blood pressure reduction. While a decrease in blood pressure is a beneficial effect, the client’s pressures remain elevated (normal range is 120/80 mm Hg). Discontinuing the infusion would remove the anticonvulsant effect, potentially increasing the risk of a seizure, which is a major complication of severe preeclampsia.
Choice B rationale
Decreasing the dosage of magnesium sulfate would reduce the therapeutic serum magnesium level. This could compromise the anticonvulsant effect needed to prevent eclamptic seizures. The current dosage should be maintained to achieve and sustain the target therapeutic range, which is typically 4.8 to 8.4 mg/dL.
Choice C rationale
The nurse should continue to monitor the client's vital signs and the effectiveness of the magnesium sulfate. The observed decrease in blood pressure from 146/90 to 141/86 mm Hg within a 10-minute interval suggests a positive therapeutic trend. This indicates the medication is having its intended effect of vasodilation. Continued monitoring is crucial to assess for further improvement or signs of toxicity.
Choice D rationale
Increasing the frequency of blood pressure checks is not the most appropriate primary action. While frequent monitoring is essential, the blood pressure values are showing a positive response. The current monitoring schedule is likely adequate. There is no immediate indication of a new complication or an acute deterioration that would warrant more frequent checks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Greenish-brown amniotic fluid indicates the presence of meconium, which is the newborn's first stool. This can be a sign of fetal distress. The first action should be to assess the fetal heart rate (FHR) to determine the current status of the fetus and identify any signs of hypoxia or compromise. The normal FHR range is 110-160 beats per minute.
Choice B rationale
While contacting the healthcare provider is an important step, it is not the first intervention. The nurse must first gather a full assessment of the fetal well-being, specifically the fetal heart rate, to provide the healthcare provider with accurate information to make an informed decision about the next steps.
Choice C rationale
Assessing cervical dilation is a routine part of labor but does not take priority over evaluating the fetal heart rate when meconium-stained amniotic fluid is present. The meconium-stained fluid is a critical finding that warrants immediate assessment of fetal well-being.
Choice D rationale
Repositioning the client to the left side can improve uterine blood flow and oxygenation to the fetus. This is a potential intervention if fetal distress is confirmed by a non-reassuring FHR. However, the initial priority is to assess the FHR to determine if distress is present.
Correct Answer is C
Explanation
Choice A rationale
While a newborn's liver is immature and can affect coagulation, phytonadione (vitamin K) is not administered to directly improve liver function. Its primary role is to provide the necessary co-factor for the synthesis of specific clotting factors, which are produced in the liver but are vitamin K dependent.
Choice B rationale
Newborns typically have insufficient dietary intake of vitamin K, but this is a secondary issue. The primary reason for administering the medication is the lack of vitamin K in the newborn's sterile gut, which is necessary for the production of clotting factors. The medication directly addresses the risk of bleeding.
Choice C rationale
Newborns have a sterile gut at birth and are unable to synthesize vitamin K, a fat-soluble vitamin essential for the hepatic synthesis of clotting factors II, VII, IX, and X. The administration of phytonadione prevents vitamin K deficiency bleeding, also known as hemorrhagic disease of the newborn. This statement shows correct understanding of the medication's purpose.
Choice D rationale
Phytonadione is not an immune system stimulant. Its function is confined to the coagulation cascade. The medication is specifically a vitamin that acts as a co-factor in the synthesis of prothrombin and other coagulation proteins. It does not play a direct role in stimulating or modulating the infant's immune response.
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