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) Have the parent fold the infant's arms across the chest is incorrect because this is not a helpful way to calm a preterm infant. Folding the arms across the chest can restrict the infant's breathing and movement, and may increase their stress and discomfort. Preterm infants need gentle and supportive touch, not restraint or pressure.
Choice b) Encourage the parent to place the infant back in the warmer is incorrect because this is not a necessary or beneficial action for a preterm infant who is showing signs of overstimulation. Placing the infant back in the warmer can interrupt the bonding and attachment process between the parent and the infant, and may make the infant feel more isolated and insecure. Preterm infants need close and frequent contact with their parents, not separation or detachment.
Choice c) Encourage the parent to do kangaroo care is correct because this is an effective and evidence-based method of soothing and stabilizing a preterm infant who is experiencing overstimulation. Kangaroo care is a technique where the parent holds the infant skin-to-skin on their chest, providing warmth, comfort, and security. Kangaroo care can reduce the infant's stress hormones, lower their heart rate and blood pressure, improve their oxygenation and breathing, enhance their growth and development, and strengthen their bond with their parent.
Choice d) Cover the infant with a warm bed blanket is incorrect because this is not a sufficient or optimal way to comfort a preterm infant who is displaying signs of overstimulation. Covering the infant with a warm bed blanket can provide some warmth and protection, but it does not offer the same benefits as kangaroo care. A warm bed blanket cannot mimic the parent's heartbeat, voice, smell, and movement, which are essential for the infant's emotional and physiological well-being. Preterm infants need human touch and interaction, not just physical warmth.
Correct Answer is C
Explanation
Choice a) Consult the physician, because the dose is too high is incorrect because this is not a necessary or appropriate action for a nurse who is following a valid order for betamethasone. Betamethasone is a corticosteroid that can be used to accelerate fetal lung maturation and reduce the risk of respiratory distress syndrome and other complications in preterm infants. The recommended dose for betamethasone is 12 mg IM every 24 hours for two doses, which is exactly what the physician ordered. Therefore, there is no reason to question or consult the physician about the dose, as it is within the normal range and based on evidence-based practice.
Choice b) Schedule the second dose for 11 am on the next day is incorrect because this is not a correct or accurate way to implement the order for betamethasone. Betamethasone should be given at least 24 hours apart, but not more than 48 hours apart, to achieve optimal fetal lung development and neonatal outcomes. Scheduling the second dose for 11 am on the next day would result in a 24-hour interval between the doses, which is acceptable, but not ideal. The best time to schedule the second dose would be between 24 and 48 hours after the first dose, such as at 11 pm on the same day or at 7 am on the next day.
Choice c) Prepare to administer the medication intramuscularly between contractions is correct because this is the best and most appropriate way to implement the order for betamethasone. Betamethasone should be given by intramuscular injection in a large muscle mass, such as the deltoid or gluteus, using a 21-gauge needle and a syringe with an air lock. The injection site should be cleaned with alcohol and aspirated before injecting. The medication should be administered between contractions, when the uterine blood flow is maximal and the fetal absorption is optimal. The nurse should also monitor the woman and the fetus for any adverse effects of betamethasone, such as maternal hyperglycemia, hypertension, infection, or edema, or fetal tachycardia, hypoglycemia, or infection.
Choice d) Explain to the woman that this medication will reduce her heart rate and help her to breathe easier is incorrect because this is not a true or relevant statement about betamethasone. Betamethasone does not have any direct effect on the maternal heart rate or respiratory function, as it is mainly intended to improve the fetal lung maturation and reduce the risk of respiratory distress syndrome and other complications in preterm infants.
Betamethasone may cause some side effects such as increased blood pressure, blood sugar, or fluid retention in the mother, which may affect her cardiovascular or respiratory status indirectly. However, these effects are usually transient and mild, and do not outweigh the benefits of betamethasone for the fetus. Therefore, this statement is misleading and inaccurate.
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