A nurse is caring for a client who has 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?
Prepare for an emergency cesarean birth.
Discontinue the medication infusion.
Place the client in Trendelenburg's position.
Assess maternal blood glucose.
The Correct Answer is B
Choice A) Prepare for an emergency cesarean birth is incorrect because this is not a priority or appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.
Preeclampsia is a condition that causes high blood pressure, proteinuria, and edema during pregnancy. It can lead to complications such as eclampsia, which is seizures, or HELLP syndrome, which is hemolysis, elevated liver enzymes, and low platelets. Magnesium sulfate is a medication that helps to prevent or treat seizures in preeclamptic clients by relaxing the muscles and nerves. However, it can also cause side effects such as respiratory depression, hypotension, or loss of reflexes. Preparing for an emergency cesarean birth may be necessary if the client has severe preeclampsia or fetal distress, but it does not address the immediate problem of magnesium toxicity. Therefore, this action should be done only when indicated by the physician and after stabilizing the client's condition.
Choice B) Discontinue the medication infusion is correct because this is a priority and appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Discontinuing the medication infusion can help to stop or reduce the adverse effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. These effects can indicate magnesium toxicity, which is a life-threatening condition that can cause cardiac arrest or coma. The nurse should also notify the physician and prepare to administer calcium gluconate, which is an antidote for magnesium toxicity. Therefore, this action should be done as soon as possible for clients who show signs of magnesium overdose.
Choice C) Place the client in Trendelenburg's position is incorrect because this is not a safe or suitable action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.
Trendelenburg's position means lying on the back with the head lower than the feet. It is sometimes used to improve blood flow to the brain or heart in cases of shock or hypotension. However, it can also cause complications such as increased intracranial pressure, decreased lung expansion, aspiration, or acid reflux. Moreover, it does not help to reverse or prevent the side effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. Therefore, this action should be avoided or used with caution for clients who are receiving magnesium sulfate IV.
Choice D) Assess maternal blood glucose is incorrect because this is not a relevant or necessary action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Blood glucose is the level of sugar in the blood that provides energy to the cells. It is measured by a blood test or a finger stick test. It can be affected by various factors such as diet, exercise, medication, or pregnancy. Assessing maternal blood glucose may be important for clients who have diabetes or gestational diabetes, which are conditions that cause high blood sugar levels that can harm the mother and the baby. However, it does not relate to preeclampsia or magnesium sulfate, which are conditions that affect blood pressure and nerve function. Therefore, this action should be done only when indicated by the physician and according to the client's history and needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice a) This could result in profound bleeding is correct because this is the primary reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination involves inserting a gloved finger or a speculum into the vagina and cervix to assess their dilation, effacement, position, and station. This can cause trauma to the cervix or the placenta, which can trigger severe hemorrhage and endanger the mother and the fetus. Therefore, this explanation is accurate and appropriate.
Choice b) This could initiate preterm labor is incorrect because this is not the main reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may stimulate uterine contractions, which can lead to preterm labor and delivery. However, this is not the most serious or likely complication of an internal examination for a client who has placenta previa, as the bleeding risk is much higher and more urgent. Therefore, this explanation is incomplete and misleading.
Choice c) There is an increased risk of introducing infection is incorrect because this is not a specific reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may introduce bacteria or other microorganisms into the vagina or cervix, which can cause infection and inflammation. However, this is a general risk that applies to any pregnant woman who undergoes an internal examination, not just those who have placenta previa. Therefore, this explanation is irrelevant and inaccurate.
Choice d) There is an increased risk of rupture of the membranes is incorrect because this is not a relevant reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may cause rupture of the membranes, which are the sacs that contain the amniotic fluid and the fetus. However, this is not a significant or common complication of an internal examination for a client who has placenta previa, as the membranes are usually located above or away from the placenta and cervix. Therefore, this explanation is improbable and inaccurate.
Correct Answer is C
Explanation
Choice A) Missed abortion: This is not the correct obstetric complication for methotrexate treatment. A missed abortion is a type of miscarriage in which the fetus has died but the products of conception are still retained in the uterus. Methotrexate is not used for this condition, as it can cause toxicity and bleeding. The usual treatment options for a missed abortion are expectant management, medical induction, or surgical evacuation.
Choice B) Abruptio placentae: This is not the correct obstetric complication for methotrexate treatment. Abruptio placentae is a condition in which the placenta separates from the uterine wall before delivery, causing bleeding and fetal distress. Methotrexate is not used for this condition, as it can worsen the bleeding and harm the fetus. The usual treatment options for abruptio placentae depend on the severity of the condition and the gestational age, but they may include fluid resuscitation, blood transfusion, tocolysis, or emergency delivery.
Choice C) Unruptured ectopic pregnancy: This is the correct obstetric complication for methotrexate treatment. An ectopic pregnancy is a pregnancy that implants outside of the uterine cavity, usually in the fallopian tube. An unruptured ectopic pregnancy is one that has not caused any bleeding or rupture of the tube. Methotrexate is used for this condition, as it can dissolve the pregnancy tissue and prevent further growth and complications.
Methotrexate is given as an injection and works by inhibiting folic acid metabolism, which is essential for cell division.
Methotrexate is only suitable for patients who have stable vital signs, low levels of human chorionic gonadotropin (hCG), and no fetal heartbeat or cardiac activity detected by ultrasound.
Choice D) Complete hydatidiform mole: This is not the correct obstetric complication for methotrexate treatment. A complete hydatidiform mole is a type of gestational trophoblastic disease in which there is an abnormal proliferation of placental tissue without any fetal development. Methotrexate is not used for this condition, as it can cause resistance and recurrence. The usual treatment option for a complete hydatidiform mole is suction curettage, which removes the molar tissue from the uterus.
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