A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation.

Exhibits
Which of the following actions should the nurse take after administering the prescribed medications? Select all that apply.

Keep calcium gluconate readily available.

Check urinary output every 2 hr.

Check deep tendon reflexes every 1 hr.

Provide intermittent fetal monitoring.

Report respiratory rate of less than 12 breaths/min to the provider.

Answer and Explanation

Correct Answer : A,C,E

A. Keep calcium gluconate readily available: Magnesium sulfate can cause toxicity, including respiratory depression and cardiac arrest. Calcium gluconate is the antidote and must be available at the bedside in case of adverse effects. This is a critical safety measure during therapy.

B. Urinary output should be monitored hourly, not every 2 hours, because magnesium is excreted by the kidneys. Reduced urine output can quickly lead to magnesium accumulation and toxicity, so frequent monitoring is essential.

C. Check deep tendon reflexes every 1 hr: Loss of deep tendon reflexes is an early sign of magnesium toxicity. Hourly assessments help detect neuromuscular depression and guide dosage adjustments. Reflex monitoring is essential during magnesium infusion.

D. Provide intermittent fetal monitoring: This is inappropriate in the context of severe hypertension and magnesium sulfate administration. Continuous fetal monitoring is required to assess fetal well-being and detect signs of distress, especially in a high-risk situation.

E. Report respiratory rate of less than 12 breaths/min to the provider: Respiratory depression is a major sign of magnesium toxicity. A respiratory rate below 12 indicates central nervous system depression and requires immediate attention. Prompt reporting allows timely intervention to prevent complications.

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Correct Answer is C

Explanation

A. Development of scoliosis in the spine: Scoliosis is a lateral curvature of the spine and is not a typical change during pregnancy. Pregnancy usually leads to lumbar lordosis, not scoliosis. This spinal shift affects posture but is not responsible for a waddling gait in pregnancy.

B. Increased blood volume leading to leg swelling: While increased blood volume can cause leg swelling and discomfort, it does not significantly alter the mechanics of walking. Edema may cause heaviness but not the joint instability seen with a waddling gait.

C. Relaxation of pelvic ligaments and joints: Pregnancy hormones like relaxin cause pelvic ligaments and joints to loosen in preparation for childbirth. This increased mobility alters pelvic alignment and stability, leading to the characteristic waddling gait.

D. Increased muscle strength in the lower extremities: Muscle strength typically does not increase during pregnancy; fatigue and reduced endurance are more common. Stronger muscles would improve balance, not cause a waddling gait, making this an unlikely factor.

A. Blood pressure of 140/90 mmHg B. Platelets 250,000/mm3 C. Right upper quadrant pain D. Fetus expected weight for gestation

Correct Answer is C

Explanation

A. Blood pressure of 140/90 mmHg: While elevated, this blood pressure reading is at the threshold of hypertension and is common in HELLP syndrome. It is not the most alarming finding unless it continues to rise or is accompanied by signs of end-organ damage.

B. Platelets 250,000/mm³: This is within the normal range and does not reflect thrombocytopenia, which is a hallmark of HELLP syndrome. A concerning platelet count would be below 100,000/mm³, suggesting a risk for bleeding complications.

C. Right upper quadrant pain: This symptom may indicate liver involvement, such as hepatic swelling or rupture, and is a serious sign in HELLP syndrome. It can signal worsening disease and the need for immediate evaluation and possible intervention.

D. Fetus expected weight for gestation: A fetus growing appropriately is a reassuring sign in pregnancy. HELLP syndrome can lead to fetal growth restriction, but expected weight indicates adequate placental function at the moment and is not an urgent concern.

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A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation. Exhibits Which of the following actions should the nurse take after administering the prescribed medications? Select all that apply.

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A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation.

Exhibits
Which of the following actions should the nurse take after administering the prescribed medications? Select all that apply.