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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, typically occurring in the first trimester. Amniocentesis is a procedure performed later in pregnancy, so hyperemesis is not a direct complication of the procedure.
Choice B rationale
Proteinuria is the presence of protein in the urine, which can be a sign of preeclampsia during pregnancy. While amniocentesis carries a small risk of complications, proteinuria is not a direct expected complication of the procedure itself.
Choice C rationale
Hemorrhage, or excessive bleeding, is a potential complication of amniocentesis because the procedure involves inserting a needle through the abdominal wall and uterus to withdraw amniotic fluid. This can potentially damage blood vessels, leading to bleeding at the insertion site or internally.
Choice D rationale
Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level. While fetal well-being is monitored during and after amniocentesis, hypoxia is not a direct complication for the mother.
Correct Answer is D
Explanation
Choice A rationale
The ventrogluteal muscle, located in the hip, is a safe site for intramuscular injections in adults and children older than seven months due to its distance from major nerves and blood vessels. However, the vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns and infants due to its well-developed muscle mass and accessibility.
Choice B rationale
The deltoid muscle, located in the upper arm, is small and not well-developed in newborns, making it an unsuitable site for intramuscular injections. There is also a risk of injury to the brachial nerve and blood vessels in this area in neonates.
Choice C rationale
The dorsogluteal muscle, located in the buttocks, is no longer the recommended site for intramuscular injections in infants and young children due to the proximity of the sciatic nerve and major blood vessels, increasing the risk of nerve damage.
Choice D rationale
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the recommended site for intramuscular injections in newborns. It is a large, well-developed muscle that is easily accessible and away from major nerves and blood vessels, making it a safe and effective site for administering vitamin K to prevent hemorrhagic disease of the newborn.
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