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 D
Explanation
Choice A: This is incorrect because both physiological and nonphysiological jaundice result from breakdown of erythrocytes. Jaundice is caused by the accumulation of bilirubin, a yellow pigment that is produced when red blood cells are destroyed. However, the rate and extent of hemolysis differ between the two types of jaundice.
Choice B: This is incorrect because kernicterus is a rare and serious complication of jaundice, not a usual outcome. Kernicterus occurs when bilirubin levels are very high and the pigment deposits in the brain, causing neurological damage. It can affect both physiological and nonphysiological jaundice, but it is more likely to occur in nonphysiological jaundice due to higher bilirubin levels and underlying conditions.
Choice C: This is incorrect because both physiological and nonphysiological jaundice begin at the head and progress down the body. This is because bilirubin accumulates in areas with high fat content, such as the skin, eyes, and brain. The distribution of jaundice depends on the level of bilirubin in the blood, not on the type of jaundice.
Choice D: This is the correct answer because nonphysiological jaundice appears in the first 24 hours of life, whereas physiological jaundice appears after the first 24 hours of life. Nonphysiological jaundice is caused by factors that increase hemolysis or impair bilirubin metabolism or excretion, such as blood group incompatibility, infection, liver disease, or enzyme deficiency. Physiological jaundice is caused by normal adaptation processes that occur after birth, such as increased red blood cell turnover, immature liver function, and delayed intestinal flora colonization.
Correct Answer is A
Explanation
Choice a) I will be certain to empty the litter boxes regularly is incorrect because this is a risky behavior for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis is an infection caused by a parasite called Toxoplasma gondii, which can be found in the feces of cats and other animals. If a pregnant woman gets infected with toxoplasmosis, she can pass it to her unborn baby, which can cause serious problems such as miscarriage, stillbirth, or birth defects. Therefore, a pregnant woman should avoid contact with cat litter and let someone else handle the litter boxes, or wear gloves and wash her hands thoroughly if she has to do it herself.
Choice b) I have to wash all of my fruits and vegetables is correct because this is a good practice for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis can also be transmitted through contaminated soil or water, which can adhere to fruits and vegetables. Therefore, a pregnant woman should wash all of her fruits and vegetables before eating them, and peel or cook them if possible, to remove any traces of the parasite.
Choice c) I won't eat raw eggs is correct because this is another good practice for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis can also be acquired through eating undercooked or raw meat or eggs that contain the parasite. Therefore, a pregnant woman should avoid eating raw eggs or any foods that contain them, such as mayonnaise, mousse, or homemade ice cream, and cook all of her meat and eggs thoroughly until they are no longer pink or runny.
Choice d) I need to be cautious when cooking meat is correct because this is also an important practice for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis can also be spread through handling raw meat that contains the parasite. Therefore, a pregnant woman should be careful when cooking meat and use separate utensils and cutting boards for raw and cooked meat, wash her hands and surfaces after touching raw meat, and avoid tasting raw meat while cooking it.
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