Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin.

The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds.

The fetal heart rate is 160 beats/minute with late decelerations.

What is the priority nursing action?

Increase the rate of oxytocin infusion

Administer oxygen via face mask at 10 L/minute

Turn the client to her left side

Notify the health care provider

Answer and Explanation

The Correct Answer is D

The correct answer is d. Notify the health care provider.

Rationale for Choice A:

Increasing the rate of oxytocin infusion is contraindicated in this situation.
Oxytocin stimulates uterine contractions, and the client is already experiencing excessively frequent and prolonged contractions.
Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
It could also put the client at higher risk for uterine rupture, a serious complication associated with oxytocin use.

Rationale for Choice B:

While administering oxygen is a common intervention for fetal distress, it's not the priority action in this case.
Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency, which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.

Rationale for Choice C:

Turning the client to her left side is a recommended position to improve placental blood flow.
However, in this situation, it's not the priority action given the presence of late decelerations and excessive uterine contractions.
It may be a helpful adjunct measure, but it won't address the primary cause of fetal distress.

Rationale for Choice D:

Notifying the health care provider is the most crucial action because:
- The client has severe pre-eclampsia, a serious condition that requires close monitoring and management.
- The frequent and prolonged contractions, along with late decelerations in the fetal heart rate, indicate potential fetal distress.
- The health care provider needs to be aware of these changes to make timely decisions regarding interventions, such as:
  - Adjusting the oxytocin infusion
  - Expediting delivery if necessary
  - Implementing other measures to improve fetal well-being
  - Closely monitoring the mother's condition to prevent complications of pre-eclampsia

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

The client has no seizures or eclampsia.This outcome would indicate that the magnesium sulfate therapy is successful because magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.

Some additional information for the other choices are:

• Choice B. The client delivers a healthy baby vaginally.

This outcome is desirable but not directly related to the effectiveness of magnesium sulfate therapy.Magnesium sulfate can help prolong a pregnancy for up to two days to allow drugs that speed up the baby’s lung development to be administered, but it does not guarantee a vaginal delivery or a healthy baby.

• Choice C. The client has normal blood pressure and urine output.

This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.

Magnesium sulfate may help reduce blood pressure in some cases, but it is not the primary treatment for hypertension in preeclampsia.Other medications such as antihypertensives are usually prescribed for that purpose.Urine output should be monitored closely while receiving magnesium sulfate therapy, as a decrease may indicate toxicity or kidney impairment.Urine output should be at least 30 mL/hour while administering magnesium sulfate.

• Choice D. The client has improved liver function and platelet count.

This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.

Magnesium sulfate does not affect liver function or platelet count in preeclampsia.These parameters may improve after delivery of the placenta, which is the main cause of preeclampsia.

Normal ranges for blood pressure, urine output, liver function and platelet count are:

• Blood pressure: less than 140/90 mm Hg

• Urine output: at least 30 mL/hour

• Liver function: AST and ALT less than 40 U/L, LDH less than 600 U/L, bilirubin less than 1.2 mg/dL

• Platelet count: 150,000 to 450,000 per microliter of blood

A. Administer calcium gluconate as an antidote if toxicity occurs B. Monitor the client’s blood glucose level every 4 hours C. Discontinue the infusion if the client’s respiratory rate is below 16/min D. Increase the infusion rate if the client’s urine output is above 30 mL/hr

Correct Answer is A

Explanation

Administer calcium gluconate as an antidote if toxicity occurs.Magnesium sulfate is a mineral that reduces seizure risks in women with severe preeclampsia.However, it can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Calcium gluconate is an antidote that can reverse the effects of magnesium sulfate and restore normal neuromuscular function.

Choice B is wrong because magnesium sulfate does not affect blood glucose levels.

There is no need to monitor the client’s blood glucose level every 4 hours.

Choice C is wrong because the infusion should be discontinued if the client’s respiratory rate is below 12/min, not 16/min.

A low respiratory rate indicates respiratory depression, which is a sign of magnesium toxicity.

Choice D is wrong because the infusion rate should not be increased if the client’s urine output is above 30 mL/hr.Urine output should be at least 30 mL/hr while administering magnesium sulfate to prevent accumulation of the drug in the body.

Increasing the infusion rate can increase the risk of toxicity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin. The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds. The fetal heart rate is 160 beats/minute with late decelerations. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with pre-eclampsia. Which outcome would indicate that the therapy is successful?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider as a sign of fetal compromise?

A nurse is teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia. What clinical indicator would suggest that the therapy is successful?

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

A nurse is caring for a client who has a diagnosis of HELLP syndrome. The nurse should monitor the client for which of the following complications? (Select all that apply.)

A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following assessments is the most important for the nurse to perform?

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).