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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

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Correct Answer is ["A","B"]

Explanation

The correct answer is A and B. A. Serum magnesium level of 8 mg/dL

This statement is correct because a serum magnesium level of 8 mg/dL (6.6 mmol/L) is within the therapeutic range for eclampsia treatment, which is 3.5 to 7 mEq/L (4.2 to 8.4 mg/dL) according to some sources, or 1.5 to 3.5 mmol/L according to others.A serum magnesium level above 8 mEq/L (10 mmol/L) can cause areflexia, respiratory paralysis, and cardiac arrest.

B. Serum calcium level of 7 mg/dL

This statement is correct because a serum calcium level of 7 mg/dL (1.75 mmol/L) is below the normal range of 8.5 to 10.2 mg/dL (2.12 to 2.55 mmol/L), which indicates hypocalcemia.Hypocalcemia is a common side effect of magnesium sulfate therapy, as magnesium competes with calcium for binding sites on plasma proteins and cell membranes, and also inhibits the release of parathyroid hormone.

C. Serum creatinine level of 1.2 mg/dL

This statement is wrong because a serum creatinine level of 1.2 mg/dL (106 umol/L) is within the normal range of 0.6 to 1.3 mg/dL (53 to 115 umol/L) for women.Serum creatinine level reflects kidney function, and renal impairment can affect the clearance of magnesium sulfate and increase the risk of toxicity.

D. Serum potassium level of 3.8 mEq/L

This statement is wrong because a serum potassium level of 3.8 mEq/L (3.8 mmol/L) is within the normal range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L) for adults.Serum potassium level reflects electrolyte balance, and hypokalemia or hyperkalemia can affect cardiac function and muscle contraction.

E. Serum sodium level of 140 mEq/L

This statement is wrong because a serum sodium level of 140 mEq/L (140 mmol/L) is within the normal range of 135 to 145 mEq/L (135 to 145 mmol/L) for adults.Serum sodium level reflects fluid balance, and hyponatremia or hypernatremia can affect brain function and blood pressure.

A. Stop the magnesium sulfate infusion B. Increase the rate of the hydralazine infusion C. Administer calcium gluconate IV push D. Prepare for immediate delivery of the fetus

Correct Answer is A

Explanation

Stop the magnesium sulfate infusion.

The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.

Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.

The nurse should stop the infusion and monitor the client’s vital signs and neurological status.

Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.

The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.

Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.

It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.

Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.

The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.

Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.

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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

(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate. Which of the following values should the nurse report to the provider? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

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 educating a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously about the possible side effects of the medication. Which of the following statements should the nurse include in the teaching?

A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin. Which of the following findings should the nurse report to the provider immediately?

A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV. Which of the following adverse effects should the nurse monitor for?

A nurse is planning to administer hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following actions should the nurse take before giving the medication? (Select all that apply.)

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

A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?