A nurse is assessing a client who has preeclampsia with severe features and is receiving intravenous magnesium sulfate. The nurse notes a respiratory rate of 8/min with absent deep tendon reflexes.
Which of the following actions is the nurse's priority?
Obtain a magnesium level.
Administer calcium gluconate.
Stop the magnesium sulfate infusion.
Take the client's blood pressure.
The Correct Answer is C
Choice A rationale
While obtaining a magnesium level is important for monitoring therapeutic range (typically 4-7 mEq/L), the client's current signs of respiratory depression (8/min) and absent deep tendon reflexes indicate severe magnesium toxicity, a life-threatening emergency. Immediate intervention is required to prevent respiratory arrest and cardiac complications.
Choice B rationale
Administering calcium gluconate is the antidote for magnesium sulfate toxicity because calcium ions competitively antagonize the effects of magnesium at the neuromuscular junction, reversing respiratory depression and cardiac effects. However, the priority action is to stop the causative agent first before administering the antidote.
Choice C rationale
Stopping the magnesium sulfate infusion is the most immediate and critical action to prevent further escalation of magnesium toxicity. The respiratory rate of 8/min is indicative of significant respiratory depression, a severe complication. Halting the infusion prevents additional magnesium from entering the bloodstream, allowing the body to excrete the excess.
Choice D rationale
Taking the client's blood pressure is part of a complete assessment; however, it is not the most immediate priority when the client is exhibiting severe signs of respiratory depression and absent deep tendon reflexes. These signs suggest impending respiratory arrest, which requires immediate intervention to preserve life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
Choice A rationale: A heart rate of 75/min in a 7-year-old child falls within the normal pediatric range of 70 to 110 beats per minute. Heart rate variability can be influenced by activity, anxiety, or health status. Since this child is alert and cooperative with no signs of distress, this heart rate is physiologically appropriate and does not indicate an urgent cardiovascular problem requiring immediate follow-up.
Choice B rationale: A pulse oximetry reading of 98% on room air is considered within normal limits for a child. Normal oxygen saturation ranges from 95% to 100% in healthy individuals, indicating adequate oxygenation and effective pulmonary gas exchange. Since the child shows no respiratory distress and oxygen saturation is stable, no immediate intervention is necessary based on this value.
Choice C rationale: A blood pressure of 148/88 mm Hg in a 7-year-old is significantly elevated. Pediatric hypertension is defined as systolic or diastolic BP at or above the 95th percentile for age, sex, and height. For this age and height, normal systolic BP is approximately 90–112 mm Hg, and diastolic is 55–75 mm Hg. This reading suggests stage 2 hypertension, requiring urgent evaluation to prevent end-organ damage.
Choice D rationale: Height of 154.9 cm (61 inches) at age 7 is above average but not concerning by itself. Growth charts indicate the 95th percentile for 7-year-old boys is around 128 cm (50 inches). This height is unusually tall, likely indicating early growth spurt or familial tall stature but does not require immediate clinical follow-up unless accompanied by other symptoms.
Choice E rationale: Weight of 44.5 kg (98 lb) at age 7 is significantly above the typical weight range, with the 95th percentile approximately 34 kg. This child is likely obese, which predisposes to hypertension and metabolic complications. However, obesity alone is not an immediate threat requiring urgent follow-up, but it warrants lifestyle counseling and monitoring.
Correct Answer is C
Explanation
Choice A rationale
Gonorrhea is a sexually transmitted infection caused by the bacterium *Neisseria gonorrhoeae*. This gram-negative diplococcus primarily infects mucous membranes of the reproductive tract, mouth, and rectum, leading to symptoms like discharge and dysuria. It is not caused by a protozoan.
Choice B rationale
Chlamydia is a sexually transmitted infection caused by the obligate intracellular bacterium *Chlamydia trachomatis*. This bacterium infects columnar epithelial cells, particularly in the genitourinary tract, often leading to asymptomatic infections or symptoms like urethritis and cervicitis. It is not a protozoal infection.
Choice C rationale
Trichomoniasis is a sexually transmitted infection caused by the anaerobic flagellated protozoan parasite *Trichomonas vaginalis*. This microorganism infects the urogenital tract, leading to vaginitis in females and urethritis in males, characterized by symptoms like itching, burning, and discharge.
Choice D rationale
Syphilis is a sexually transmitted infection caused by the spirochete bacterium *Treponema pallidum*. This bacterium can disseminate throughout the body, causing a multi-stage disease with diverse clinical manifestations affecting skin, mucous membranes, and internal organs. It is not caused by a protozoan.
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