A nurse is caring for a 40-year-old female client, gravida 2, para 2, at 36 weeks gestation with moderate preeclampsia in the labor and delivery unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress
The Correct Answer is []
Rationale for correct condition The client presents with classic signs of magnesium sulfate toxicity: absent DTRs, respiratory rate of 10 breaths/min, and decreased consciousness. Normal DTRs should be 2+; absence indicates neuromuscular depression. Magnesium impairs acetylcholine release, affecting neuromuscular and respiratory systems. A normal serum magnesium level is 1.7–2.2 mg/dL; toxicity often occurs above 7 mg/dL. Urine output <30 mL/hour also suggests impaired renal clearance.
Rationale for correct actions Stopping the infusion halts further accumulation of magnesium, preventing progression to respiratory arrest or cardiac dysfunction. Magnesium is eliminated renally; continued infusion worsens toxicity. Calcium gluconate is the antidote to magnesium toxicity because it competitively antagonizes magnesium’s action at neuromuscular junctions, restoring muscle tone and respiration. Calcium stabilizes cardiac membrane potentials affected by excess magnesium.
Rationale for correct parameters Serum magnesium level directly confirms toxic accumulation above the therapeutic range. Monitoring provides a quantifiable measure to guide treatment. DTRs reflect central and peripheral neuromuscular function; their absence signals excessive magnesium levels impairing synaptic transmission.
Rationale for incorrect conditions Worsening preeclampsia causes elevated blood pressure and hyperreflexia, not hypotension or absent DTRs. Pulmonary edema exacerbation presents with crackles and hypoxia, but does not explain CNS depression or bradypnea. Hypotension secondary to medication would not cause absent DTRs or respiratory depression unless cardiac output is critically impaired.
Rationale for incorrect actions Increasing oxygen does not reverse magnesium toxicity’s neuromuscular depression. Notifying the provider is necessary but insufficient alone. Initiating seizure precautions addresses eclampsia risk, not magnesium toxicity symptoms.
Rationale for incorrect parameters Respiratory rate alone doesn't quantify magnesium status. Urine output indicates renal function but not magnesium level directly. Blood pressure trends aren’t reliable indicators of magnesium toxicity progression.
Take-home points • Magnesium sulfate toxicity presents with bradypnea, absent DTRs, and CNS depression. • Calcium gluconate is the physiological antidote via calcium channel antagonism. • Serum magnesium levels and DTRs are the most sensitive indicators of toxicity. • Differentiation from worsening preeclampsia is vital to prevent mismanagement.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The let-down reflex is primarily mediated by oxytocin's effect on myoepithelial cells surrounding the alveoli in the mammary glands. This action causes milk ejection, not activation of the reflex itself. Prolactin is the hormone primarily responsible for milk production, while oxytocin's role is specifically in the mechanical release of the milk.
Choice B rationale
Involution, the process of the uterus returning to its pre-pregnancy size, is a gradual process that occurs over several weeks. While oxytocin's uterine contractions contribute to this process by compressing blood vessels and promoting uterine tone, it is not the immediate and primary outcome. This long-term process is influenced by many hormonal and physiological changes.
Choice C rationale
Oxytocin is a neuropeptide and a potent uterotonic agent. It works by binding to specific receptors on the smooth muscle cells of the myometrium, leading to increased intracellular calcium concentrations. This cascade of events triggers strong, rhythmic contractions, which are essential for labor induction and postpartum hemorrhage prevention.
Choice D rationale
While oxytocin-induced uterine contractions are crucial for the third stage of labor, which involves placental expulsion, the direct and primary action of the administered hormone is the stimulation of those contractions. The expulsion of the placenta is the clinical outcome resulting from the physiological action of the uterine muscle contracting.
Correct Answer is C
Explanation
Choice A rationale
Preparation for an emergency cesarean birth is an important consideration in any labor, especially when augmentation is initiated. However, it is not the most immediate and direct parameter to monitor in response to oxytocin's physiological effects on uterine activity. While a C-section is a potential outcome if labor fails to progress or if fetal distress occurs, the primary focus is on the current uterine and fetal response to the medication.
Choice B rationale
Checking the perineum for bulging is a part of routine labor assessment, indicating the fetal head is descending and nearing delivery. While important for evaluating labor progress, it is not the most critical parameter for a nurse to monitor in direct response to the initiation of an oxytocin drip. Bulging would be a later sign of progress, not an immediate indicator of the medication's effect on uterine contractility.
Choice C rationale
The intensity, interval, and length of contractions are the most crucial parameters to monitor because oxytocin directly stimulates uterine smooth muscle cells to contract. Close monitoring ensures the medication is achieving its therapeutic effect of augmenting labor without causing hyperstimulation, which could compromise fetal oxygenation and lead to fetal distress. The goal is to achieve an adequate contraction pattern, typically with contractions every 2-3 minutes, lasting 40-60 seconds, with moderate intensity.
Choice D rationale
Monitoring the client's hourly blood pressure is a standard nursing responsibility during labor. However, oxytocin's primary mechanism of action is on uterine smooth muscle, not systemic hemodynamics. While large doses can have an antidiuretic effect, increasing blood pressure is not the most immediate and critical parameter to monitor in response to the drip's initiation, especially when the goal is to assess the medication's intended effect on uterine activity.
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