A nurse is caring for a client diagnosed with preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
Assess maternal blood glucose.
Place the client in Trendelenburg position.
Prepare for an emergency cesarean birth.
Discontinue the medication infusion.
The Correct Answer is D
Explanation:
A. Assess maternal blood glucose:
While assessing blood glucose levels is important in clients receiving magnesium sulfate due to its potential effects on blood sugar, it is not the priority action in this scenario. The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular effects. Therefore, the immediate concern is addressing the magnesium toxicity rather than assessing blood glucose levels.
B. Place the client in Trendelenburg position:
Placing the client in Trendelenburg position is not indicated for magnesium toxicity. The Trendelenburg position involves placing the client in a supine position with the legs elevated higher than the head. While this position may be used in some situations (e.g., hypotension), it is not appropriate for treating magnesium toxicity, respiratory depression, or absent deep-tendon reflexes. Placing the client in Trendelenburg position may worsen respiratory function and is not recommended in this case.
C. Prepare for an emergency cesarean birth:
While severe preeclampsia or eclampsia may necessitate emergency cesarean birth in some cases, it is not the immediate action needed for a client experiencing respiratory depression and absent deep-tendon reflexes due to magnesium sulfate toxicity. Cesarean birth is not the appropriate response to magnesium toxicity and would not address the client's current respiratory and neuromuscular issues. Therefore, preparing for an emergency cesarean birth is not the correct action in this scenario.
D. Discontinue the medication infusion:
This is the correct action to take. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Magnesium sulfate, while effective in preventing seizures in preeclampsia, can lead to respiratory depression and affect neuromuscular function at toxic levels. Discontinuing the medication infusion is crucial to prevent further magnesium toxicity and adverse effects on the client's respiratory and neuromuscular status. It is the immediate and priority action needed to address the client's current condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation:
A. Prepare the abdominal and perineal areas: While preparing the abdominal and perineal areas may be necessary for potential interventions, such as a cesarean section or vaginal examination, it is not the priority at this moment.
B. Witness the signature for informed consent for surgery: Obtaining informed consent for surgery is important, especially if surgical intervention is anticipated. However, the priority in this case is to stabilize the client's condition and address the potential causes of painless, bright red vaginal bleeding.
C. Insert an indwelling urinary catheter: Inserting an indwelling urinary catheter may be beneficial for monitoring urinary output and assessing fluid status. However, it is not the immediate priority compared to addressing the client's vital signs and managing potential causes of bleeding.
D. Initiate IV access: This is the correct answer. Given the client's large amount of painless, bright red vaginal bleeding, the priority is to establish IV access to administer fluids and possibly blood products if there is evidence of hypovolemia or hemorrhage. IV access will also allow for the administration of medications or other interventions as needed.
Correct Answer is D
Explanation
Explanation:
A. This test assesses fetal lung maturity.
The explanation provided is incorrect. The maternal serum alpha-fetoprotein (MSAFP) test is not used to assess fetal lung maturity. Fetal lung maturity is typically assessed through tests such as amniocentesis, which evaluates factors like the lecithin-to-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) levels in amniotic fluid.
B. This test identifies an Rh incompatibility between the mother and fetus.
The explanation provided is also incorrect. The MSAFP test is not used to identify Rh (Rhesus) incompatibility between the mother and fetus. Rh incompatibility is determined through other tests, such as blood typing (Rh factor) and antibody screening.
C. It assesses various markers of fetal well-being.
This explanation is not accurate. While the MSAFP test does provide information about certain fetal abnormalities, it is primarily used as a screening test for neural tube defects (spinal defects) and abdominal wall defects rather than assessing overall fetal well-being, which involves a comprehensive evaluation of various fetal parameters.
D. It is a screening test for spinal defects in the fetus.
This explanation is correct. The MSAFP test is indeed a screening test specifically used to assess the risk of spinal defects, also known as neural tube defects, in the fetus. These defects include conditions such as spina bifida. The test measures the levels of alpha-fetoprotein in the mother's blood to screen for these abnormalities during pregnancy.
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