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 C
Explanation
Choice a) D5W intravenously is incorrect because this is not the preferred method of feeding for a hypoglycemic infant. D5W stands for dextrose 5% in water, which is a solution that contains glucose and water. It can be used to treat hypoglycemia by providing a source of energy and fluid to the infant. However, it has several disadvantages, such as requiring an invasive procedure, increasing the risk of infection, causing fluid overload or electrolyte imbalance, and stimulating insulin secretion, which can lead to rebound hypoglycemia. Therefore, D5W intravenously should be reserved for severe cases of hypoglycemia that do not respond to oral or enteral feeding.
Choice b) Formula via nasogastric tube is incorrect because this is not the first-line option of feeding for a hypoglycemic infant. Formula is an artificial substitute for breast milk that contains nutrients and calories to support the infant's growth and development. It can be given via nasogastric tube, which is a tube that passes through the nose and into the stomach, when the infant cannot suck or swallow effectively. However, formula has several disadvantages, such as being less digestible, less immunogenic, and less adaptable than breast milk, as well as increasing the risk of necrotizing enterocolitis, allergy, or infection. Therefore, formula via nasogastric tube should be used only when breast milk is unavailable or contraindicated.
Choice c) Breast milk is correct because this is the best and most recommended type of feeding for a hypoglycemic infant. Breast milk is the natural and optimal food for infants that contains all the nutrients and antibodies they need to grow and thrive. It can be given directly from the breast or expressed and fed by bottle or cup. Breast milk has several advantages, such as being easily digestible, enhancing immune function, promoting bonding, and adjusting to the infant's needs. Breast milk also contains lactose, which is a natural sugar that can raise the blood glucose level of the infant without causing a spike in insulin secretion. Therefore, breast milk should be offered to the hypoglycemic infant as soon as possible after birth and at regular intervals thereafter.
Choice d) Glucose water in a bottle is incorrect because this is not an appropriate type of feeding for a hypoglycemic infant. Glucose water is a solution that contains glucose and water. It can be given by bottle or cup to provide a quick source of energy to the infant. However, it has several disadvantages, such as providing no other nutrients or calories, interfering with breastfeeding, causing diarrhea or dehydration, and stimulating insulin secretion, which can lead to rebound hypoglycemia. Therefore, glucose water in a bottle should be avoided or used sparingly for mild cases of hypoglycemia that do not respond to breast milk.
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.
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