A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?
Administer calcium gluconate
Discontinue the infusion.
Assess the fetal heart rate.
Obtain the client's magnesium level.
The Correct Answer is B
A. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity, but it should be given after stopping the infusion and assessing the client’s respiratory status. Immediate discontinuation takes priority.
B. Discontinue the infusion: Difficulty breathing indicates a potential magnesium sulfate toxicity or respiratory depression, which is a life-threatening emergency. The first action is to stop the infusion to prevent further accumulation.
C. Assess the fetal heart rate: Monitoring the fetus is important, but maternal safety takes priority over fetal assessment in a potential toxic reaction. Stabilizing the mother comes first.
D. Obtain the client's magnesium level: Lab assessment is useful for confirming toxicity, but it should not delay immediate intervention. Stopping the infusion takes precedence over obtaining levels.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Provide a tracheostomy tray at the bedside: A tracheostomy tray is not routinely required for seizure precautions, as airway obstruction in seizures is usually managed through positioning and suctioning.
B. Place the client in supine position: The supine position can increase the risk of airway obstruction and aspiration after a seizure. A side-lying position is preferred to help maintain an open airway and promote drainage of secretions.
C. Place a plastic tongue depressor at the client's bedside: Placing any object in a client’s mouth during or after a seizure can cause injury to the teeth, gums, or airway. Modern seizure precautions avoid using tongue blades or depressors entirely.
D. Insert an IV saline lock: Having IV access readily available allows rapid administration of emergency medications such as benzodiazepines if the client experiences another seizure. This intervention supports prompt treatment and stabilization.
Correct Answer is C
Explanation
A. Bleeding gums: Mild bleeding gums can occur during pregnancy due to increased vascularity and hormonal changes. While uncomfortable, this finding is generally not urgent and can be managed with routine oral care.
B. Fundal height of 26 cm: A fundal height slightly above the gestational age (24 weeks vs. 26 cm) may be within normal variation, especially if the client has a larger fetus or multiple gestations. It should be monitored but is not immediately concerning.
C. Periorbital edema: Swelling around the eyes can be an early sign of preeclampsia, a potentially serious pregnancy complication. This finding should be reported promptly to the provider for further assessment and management.
D. White vaginal discharge: Mild, white, and non-odorous discharge (leukorrhea) is common during pregnancy due to hormonal changes. It is typically considered normal unless accompanied by odor, itching, or irritation.
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