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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, it’s common for women to have difficulty emptying their bladder. If the bladder becomes too full, it can push the uterus to one side.

Choice B rationale

Frequent uterine contractions are not typically associated with a distended bladder. After childbirth, it’s normal for women to experience contractions as the uterus begins to shrink back to its pre-pregnancy size.

Choice C rationale

Increased thirst is not typically a sign of a distended bladder. It’s common for women to feel thirsty as their body adjusts after childbirth.

Choice D rationale

Less than 2.5 cm of rubra lochia on the perineal pad is not typically a sign of a distended bladder. Lochia is the vaginal discharge women experience after childbirth. It’s not related to bladder function.

A. “Perhaps you should see a counselor to discuss these feelings further.”. B. “Have you spoken to your mother about these feelings?” C. “Don’t worry.You will be fine once the baby is born.”. D. “Ambivalent feelings are quite common for women early in pregnancy.”. .

Correct Answer is D

Explanation

Choice A rationale

While seeing a counselor could be beneficial for some women experiencing doubts and second thoughts about their pregnancy, suggesting this as an initial response may make the client feel that her feelings are abnormal or require professional help.

Choice B rationale

Asking if the client has spoken to her mother about these feelings assumes that the client has a good relationship with her mother or that her mother is available for support, which may not be the case.

Choice C rationale

Telling the client not to worry and that she will be fine once the baby is born may minimize her feelings and does not acknowledge her current emotional state.

Choice D rationale

Ambivalent feelings are quite common for women early in pregnancy. This response validates the client’s feelings and reassures her that what she is experiencing is normal.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client’s bladder is distended?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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?