A nurse is assisting with monitoring a client who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8/min. Which of the following should the nurse administer?
Calcium gluconate.
Naloxone.
Flumazenil.
Protamine sulfate.
The Correct Answer is A
Choice A rationale :
The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.
Choice B rationale
Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.
Choice C rationale
Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.
Choice D rationale
Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The cervix is dilated 3 cm: This indicates the width of the cervical opening, which is 3 cm wide.
It is effaced 30%: This means the cervix has effaced or thinned out by 30%, indicating how much the cervix has shortened and thinned in preparation for labor.
The presenting part is 1 cm above the ischial spines (indicated by the negative number, -1): This measurement shows the position of the baby's head in relation to the ischial spines of the pelvis. In this case, the baby's head is 1 cm above the ischial spines.
Option A ("The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines."): This option incorrectly interprets the baby's position as being 1 cm below the ischial spines, which is not the case. The negative sign (-1) in the documentation indicates that the presenting part is 1 cm above the ischial spines.
Option B ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines."): This option switches the interpretation of dilation and effacement. In the original documentation, the dilation is given as 3 cm, while effacement is 30%. This option incorrectly states that effacement is 3 cm and dilation is 30%. Additionally, it correctly identifies the presenting part's position.
Option C ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines."): This option correctly interprets effacement and dilation but incorrectly states that the presenting part is 1 cm below the ischial spines. The original documentation indicates that the presenting part is 1 cm above the ischial spines, as denoted by the negative sign (-1).
Correct Answer is A
Explanation
Step 1 is assessing heart rate. A heart rate of 130/min earns 2 points since a rate above 100/min is optimal.
Step 2 is assessing respiratory effort. A lusty cry earns 2 points as strong crying indicates good respiratory function.
Step 3 is assessing muscle tone. Flexed extremities earn 1 point since full active movement would score 2.
Step 4 is assessing reflex irritability. Grimace when suctioned earns 1 point as a vigorous response (cough, sneeze) would score 2.
Step 5 is assessing color. Acrocyanosis earns 1 point since a fully pink body scores 2.
Final answer: 7
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