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 B
Explanation
Choice A) Antihypertensive: This is not the correct classification of magnesium sulfate. Antihypertensives are drugs that lower blood pressure, such as beta blockers, calcium channel blockers, or angiotensin-converting enzyme inhibitors. Magnesium sulfate does not have a significant effect on blood pressure, and it is not used as a primary treatment for hypertension in preeclampsia.
Choice B) Anticonvulsant: This is the correct classification of magnesium sulfate. Anticonvulsants are drugs that prevent or reduce the frequency and severity of seizures, such as phenytoin, valproic acid, or carbamazepine.
Magnesium sulfate is used as a prophylactic and therapeutic agent for eclampsia, which is a life-threatening complication of preeclampsia characterized by seizures. Magnesium sulfate acts by blocking the neuromuscular transmission and reducing the cerebral edema and vasospasm.
Choice C) Tocolytic: This is not the correct classification of magnesium sulfate. Tocolytics are drugs that inhibit uterine contractions and delay preterm labor, such as terbutaline, nifedipine, or indomethacin. Magnesium sulfate is not effective as a tocolytic agent, and it is not recommended for this purpose by the American College of Obstetricians and Gynecologists.
Choice D) Diuretic: This is not the correct classification of magnesium sulfate. Diuretics are drugs that increase urine output and reduce fluid retention, such as furosemide, hydrochlorothiazide, or spironolactone. Magnesium sulfate does not have a diuretic effect, and it can cause fluid overload and pulmonary edema if administered in excess.
Correct Answer is D
Explanation
Choice a) Placenta previa is incorrect because this is a condition where the placenta partially or completely covers the cervix, which can cause painless vaginal bleeding in the third trimester. It is not related to trauma and does not require hospitalization unless bleeding occurs.
Choice b) Dehydration is incorrect because this is a condition where the body loses more fluid than it takes in, which can cause symptoms such as thirst, dry mouth, headache, fatigue, and dizziness. It is not a complication of pregnancy and can be prevented by drinking enough water and avoiding caffeine and alcohol.
Choice c) Gestational hypertension is incorrect because this is a condition where the blood pressure rises above 140/90 mmHg after 20 weeks of pregnancy, which can cause complications such as preeclampsia, eclampsia, and fetal growth restriction. It is not caused by trauma and can be managed by regular antenatal care and medication if needed.
Choice d) Abruptio placentae is correct because this is a condition where the placenta separates from the uterine wall before delivery, which can cause severe vaginal bleeding, abdominal pain, uterine contractions, and fetal distress. It is a life-threatening emergency that can be triggered by trauma and requires immediate delivery of the baby and treatment of shock and blood loss. Therefore, a woman who is 8 months pregnant and involved in a serious motor vehicle crash should be admitted to the hospital for observation for this complication.
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