A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent.
What action should the nurse take?
Prepare for an emergency cesarean birth
Position the client in Trendelenburg
Discontinue the medication infusion
Assess maternal blood glucose
The Correct Answer is C
Choice A rationale
Preparing for an emergency cesarean birth may be necessary in some cases of preeclampsia, particularly if there are signs of fetal distress or if the condition is not responding to treatment. However, in this scenario, the client’s symptoms are indicative of magnesium toxicity, not worsening preeclampsia.
Choice B rationale
Positioning the client in Trendelenburg (with the head lower than the feet) is not typically used in the management of preeclampsia or magnesium toxicity.
Choice C rationale
Discontinuing the medication infusion is the correct action in this scenario. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) are indicative of magnesium toxicity, a potential complication of magnesium sulfate therapy. Magnesium sulfate is used in the management of preeclampsia to prevent seizures, but it can cause toxicity if the levels become too high. If signs of toxicity occur, the infusion should be discontinued immediately.
Choice D rationale
Assessing maternal blood glucose may be necessary in some cases, particularly if the client has a history of diabetes. However, it is not the priority in this scenario, as the client’s symptoms are indicative of magnesium toxicity, not hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Heart rate of 170. A heart rate of 170 is not a symptom of transient tachypnea of the newborn.
Choice B rationale
Grunting or sighing with respirations. This is a symptom of transient tachypnea of the newborn.
Choice C rationale
Nasal flaring. This is a symptom of transient tachypnea of the newborn.
Choice D rationale
Respirations of 72. This is a symptom of transient tachypnea of the newborn.
Correct Answer is A
Explanation
Choice A rationale
Regular physical activity plays a key role in managing gestational diabetes. The American College of Obstetricians and Gynecologists (ACOG) recommends aiming for 150 minutes of moderate-level exercise each week during pregnancy. Reducing the exercise schedule to 3 days a week may not provide the recommended amount of physical activity needed to manage gestational diabetes effectively.
Choice B rationale
Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It is usually taken before breakfast or the first main meal of the day.
Choice C rationale
This statement is correct. Women who have had gestational diabetes have an increased risk of developing type 2 diabetes later in life.
Choice D rationale
This statement is correct. A diet that includes about 40% to 45% carbohydrates is recommended for managing gestational diabetes.
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