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 B
Explanation
Explanation:
G - Gravida: The number of pregnancies, including the current one.
T - Term births: The number of pregnancies carried to term, typically considered 37 weeks or more.
P - Preterm births: The number of pregnancies delivered between 20 and 37 weeks.
A - Abortions: The number of pregnancies terminated before 20 weeks, including elective abortions and miscarriages.
L - Living children: The number of living children.
Now let's analyze the client's history:
Elective abortion at 9 weeks (terminated pregnancy): This counts as an abortion (A).
Birth of twins at 36 weeks (term births): This counts as two term births (T).
Spontaneous abortion at 15 weeks (miscarriage): This also counts as an abortion (A).
Based on the information provided, the client's GTPAL status would be:
Gravida: 4 (1 terminated pregnancy + 1 twin birth + 1 miscarriage + 1 current pregnancy)
Term births: 2 (1 twin birth)
Preterm births: 0
Abortions: 2 (1 terminated pregnancy + 1 miscarriage)
Living children: 2 (1 twin birth)
Correct Answer is B
Explanation
Explanation:
To calculate the estimated date of delivery (EDD) based on the client's last menstrual period (LMP), the nurse can use Naegele's rule. Naegele's rule calculates the EDD by adding 7 days to the first day of the LMP, subtracting 3 months, and then adding 1 year.
Given the client's last menstrual period was July 4, 2020, we can apply Naegele's rule:
Add 7 days to July 4, 2020: July 11, 2020
Subtract 3 months: April 11, 2020
Add 1 year: April 11, 2021
Therefore, the appropriate response by the nurse is:
B. April 11, 2021
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today