A nurse is caring for a client with gestational hypertension who has been prescribed magnesium sulfate to prevent seizures related to preeclampsia.
Which of the following assessments should the nurse prioritize?
Respiratory rate and depth
Urine output and color
Blood pressure and heart rate
Level of consciousness and reflexes
The Correct Answer is D
The correct answer is choice D) Level of consciousness and reflexes. This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes. These are signs that the dose of magnesium sulfate should be reduced or stopped.
The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.
Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.
Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures. However, urine output should be monitored to ensure adequate hydration and renal function.
Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy. Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.
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Correct Answer is B
Explanation
The correct answer is choice B. The client’s urine output is at least 30 mL/hr.This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.
A normal urine output is a sign that the kidneys are functioning well and that the fluid balance is maintained.
Choice A is wrong because the client’s blood pressure may not normalize even with magnesium sulfate therapy.
Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure.Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.
Choice C is wrong because the client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant.
A normal reflex response is 2+, but a lower response (1+ or 0) may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.
Choice D is wrong because the client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.
A normal respiratory rate is 12 to 20 breaths per minute, but a lower rate (less than 12) may indicate magnesium toxicity, which requires immediate treatment with calcium gluconate.
Correct Answer is D
Explanation
The correct answer is choice D) Swelling of the face, hands or feet.This is one of the signs and symptoms of gestational hypertension, which is high blood pressure that begins after 20 weeks of pregnancy and goes away after delivery.Gestational hypertension can lead to complications for both the mother and the baby, such as preeclampsia, which is a severe condition that causes protein in the urine and other problems.
Choice A) Severe headache is wrong because it is not a specific sign of gestational hypertension, but it can be a symptom of preeclampsia, which is a possible complication of gestational hypertension.
Choice B) Chest pain is wrong because it is not a common sign of gestational hypertension, but it can be a sign of a serious heart problem or a pulmonary embolism, which is a blood clot in the lungs.Chest pain during pregnancy should be evaluated by a doctor as soon as possible.
Choice C) Nausea or vomiting is wrong because it is not a typical sign of gestational hypertension, but it can be a symptom of preeclampsia or other conditions such as hyperemesis gravidarum, which is severe nausea and vomiting during pregnancy that can lead to dehydration and weight loss.
Normal blood pressure ranges for pregnant women are below 120/80 mm Hg.Gestational hypertension is diagnosed when the blood pressure is greater than or equal to 140/90 mm Hg after 20 weeks of pregnancy.
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