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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Explanation:

A. Gradual lordosis:

Gradual lordosis refers to an increased curvature of the lower spine (lumbar region). During pregnancy, as the uterus enlarges and the center of gravity shifts forward, the body compensates by increasing the curve of the lower spine. This change helps maintain balance and stability as the woman's abdomen expands due to the growing fetus. It is considered a normal adaptation to pregnancy and is often observed in the third trimester.

B. Decreased mobility of pelvic joints:

This statement is incorrect in the context of pregnancy. In fact, during pregnancy, the hormone relaxin is released, which causes relaxation and increased mobility of pelvic joints. This increased mobility is important for allowing the pelvis to expand during childbirth, facilitating the passage of the baby through the birth canal. Therefore, decreased mobility of pelvic joints is not an expected physiologic change during pregnancy.

C. Posterior neck flexion:

Posterior neck flexion refers to bending the neck backward. This is not typically associated with pregnancy-related changes. Pregnancy-related changes mainly affect the abdominal area, lower back, and pelvis rather than the neck. Therefore, posterior neck flexion is not an expected physiologic change during pregnancy.

D. Increased abdominal muscle tone:

During pregnancy, the abdominal muscles often experience stretching and relaxation rather than increased tone. This is because the growing uterus and fetus require more space, leading to abdominal wall stretching. The abdominal muscles may become less toned and more relaxed to accommodate the expanding uterus. Therefore, increased abdominal muscle tone is not an expected physiologic change during pregnancy.

A. "You will need to double your intake of iron during pregnancy." B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy." C. "You will need to increase your calcium intake during breast feeding." D. "Vitamin E requirements decline during pregnancy due to the increase in body fat."

Correct Answer is C

Explanation

Explanation:

A. "You will need to double your intake of iron during pregnancy."

This statement is not accurate. While iron needs do increase during pregnancy to support the increased blood volume and fetal development, the recommended increase is not necessarily a doubling of intake. Specific iron requirements can vary based on individual factors, such as pre-pregnancy iron status and maternal health conditions.

B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy."

Prenatal vitamins typically contain some vitamin D, but they may not meet the increased need for vitamin D during pregnancy entirely, especially if the client has limited sun exposure or other risk factors for vitamin D deficiency. Additional sources of vitamin D, such as sunlight exposure and dietary sources, may be recommended.

C. "You will need to increase your calcium intake during breastfeeding."

This statement is correct. During breastfeeding, calcium requirements increase to support milk production and the maintenance of maternal bone health. Adequate calcium intake is important for both the mother and the growing infant.

D. "Vitamin E requirements decline during pregnancy due to the increase in body fat."

This statement is not accurate. Vitamin E requirements do not necessarily decline during pregnancy because of an increase in body fat. Vitamin E is still essential during pregnancy for its antioxidant properties and role in fetal development.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?

Correct Answer is A

Explanation

A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?

Correct Answer is C

Explanation

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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?

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