A nurse is caring for a client who has eclampsia and is receiving magnesium sulfate and hydralazine.

The client’s blood pressure is 150/90 mmHg, pulse is 88/min, respirations are 18/min, and oxygen saturation is 97%.

The nurse notes that the client’s deep tendon reflexes are absent.

Which of the following actions should the nurse take?

Stop the magnesium sulfate infusion

Increase the rate of the hydralazine infusion

Administer calcium gluconate IV push

Prepare for immediate delivery of the fetus

Answer and Explanation

The Correct Answer is A

Stop the magnesium sulfate infusion.

The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.

Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.

The nurse should stop the infusion and monitor the client’s vital signs and neurological status.

Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.

The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.

Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.

It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.

Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.

The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.

Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.

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Correct Answer is C

Explanation

Headache unrelieved by analgesics.This is because headache is a common symptom of HELLP syndrome, a rare pregnancy complication that can cause high blood pressure, seizures, stroke or liver rupture.HELLP syndrome is a type of preeclampsia and has similar symptoms.

Choice A is wrong because breast engorgement is a normal postpartum condition that occurs when the breasts are full of milk and become swollen and tender.

It is not related to HELLP syndrome.

Choice B is wrong because lochia rubra for 3 days postpartum is a normal finding that indicates the shedding of the uterine lining after delivery.

It is not related to HELLP syndrome.

Choice D is wrong because perineal discomfort is a common postpartum discomfort that results from the stretching and tearing of the perineal tissues during vaginal delivery.

It is not related to HELLP syndrome.

Normal ranges for blood pressure are less than 120/80 mmHg, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT.

A. Serum creatinine of 1.2 mg/dL B. Liver enzymes of 40 U/L C. Platelet count of 100,000/mm3 D. Coagulation profile of 12 seconds E. Urine output of 20 mL/hour

Correct Answer is ["C","E"]

Explanation

The correct answer is choice C and E.A platelet count of 100,000/mm3 is low and indicates a risk of bleeding due to preeclampsia.A urine output of 20 mL/hour is also low and suggests kidney impairment due to magnesium sulfate therapy.

Both of these results should be reported to the provider as they may require intervention.

Choice A is wrong because a serum creatinine of 1.2 mg/dL is within the normal range of 0.6 to 1.3 mg/dL for womenand does not indicate kidney dysfunction.

Choice B is wrong because liver enzymes of 40 U/L are within the normal range of 7 to 55 U/L for women and do not indicate liver damage.

Choice D is wrong because a coagulation profile of 12 seconds is within the normal range of 11 to 13.5 seconds for women and does not indicate a clotting disorder.

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following results should the nurse notify the provider about? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate. Which of the following values should the nurse report to the provider? (Select all that apply.)

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who has eclampsia. Which of the following outcomes indicates that the therapy is successful?

A nurse is teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with pre-eclampsia. Which outcome would indicate that the therapy is successful?

A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin. Which of the following findings should the nurse report to the provider immediately?

A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following actions should the nurse take?

A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should alert the nurse to suspect magnesium toxicity?