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A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.
Select all nursing interventions that apply in the care for the client.

Monitor deep tendon reflexes hourly.

Notify the physician if urinary output is less than 30 ml per hour.

Keep calcium gluconate on hand in case of a magnesium sulfate overdose.

Monitor maternal vital signs every 6 hours.

Monitor intake and output hourly.

Monitor renal function and cardiac function closely.

Answer and Explanation

Correct Answer : A,B,C,E,F

Choice A rationale

Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.

Choice B rationale

A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.

Choice C rationale

Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.

Choice E rationale

Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.

Choice F rationale

Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The condition that poses the greatest risk to the newborn is meconium aspiration syndrome due to amniotic fluid.

Rationale for correct answers

Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid, leading to airway obstruction, chemical pneumonitis, and surfactant dysfunction. The presence of dark brown-greenish amniotic fluid, along with mild respiratory distress (nasal flaring, increased respiratory rate of 60/min), raises concern for MAS. Close monitoring for worsening respiratory symptoms is essential.

Amniotic fluid contamination with meconium increases the risk of lung inflammation and infection. The newborn’s vigorous condition suggests mild aspiration, but continuous observation is needed.

Rationale for incorrect Response 1 options

Jaundice: While term newborns may develop physiological jaundice, there are no indications of hyperbilirubinemia or hemolysis in this case.
Hypoglycemia: No jitteriness or poor feeding, and birth weight is within normal range; hypoglycemia more commonly affects preterm or low birth weight infants.
Cold stress: The newborn is under a radiant warmer, and temperature is within normal range (36.5°C).

Rationale for incorrect Response 2 options

Birth weight: No signs of growth restriction or macrosomia-associated complications.
Acrocyanosis: Normal in newborns due to immature circulation, not an indicator of respiratory compromise.
Apgar scores: Strong Apgar scores (8 and 9) suggest good adaptation to extrauterine life.

A. Encouraging the woman to assume a hands-and-knees position. B. Providing a comfortable environment with dim lighting. C. Administering oxytocin. D. Preparing the woman for an amniotomy.

Correct Answer is C

Explanation

Choice A rationale

Encouraging a hands-and-knees position can help rotate a fetus in an occiput posterior position or relieve back pain during labor. However, in hypotonic uterine dysfunction where contractions are weak and ineffective, this positional change alone is unlikely to augment labor significantly.

Choice B rationale

Providing a comfortable environment with dim lighting can reduce anxiety and promote relaxation, which might indirectly support labor progress. However, it does not directly address the issue of weak and ineffective uterine contractions characteristic of hypotonic dysfunction.

Choice C rationale

Administering oxytocin is the typical intervention for hypotonic uterine dysfunction after ruling out fetopelvic disproportion. Oxytocin is a synthetic hormone that stimulates uterine contractions, increasing their frequency, duration, and intensity to facilitate labor progress. It acts on the oxytocin receptors in the uterus, leading to smooth muscle contraction.

Choice D rationale

Preparing for an amniotomy (artificial rupture of membranes) might be considered to augment labor if the membranes are intact. However, since the woman's membranes have already ruptured, this intervention is not applicable in this situation. Amniotomy can sometimes stimulate or augment labor by releasing prostaglandins.

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A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.Select all nursing interventions that apply in the care for the client.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who is 30 minutes old in the newborn nursery. Exhibits The condition that poses the greatest risk to the newborn is dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out.Which intervention would the nurse expect to include in the plan of care for this client?

Correct Answer is C

Explanation

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A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.
Select all nursing interventions that apply in the care for the client.