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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 C

Explanation

Choice A rationale

Placenta previa is a condition where the placenta partially or totally covers the cervix. While it poses risks for hemorrhage during labor and delivery, it does not directly increase the risk of postpartum infection. The primary risks associated with placenta previa are related to bleeding, not infection.

Choice B rationale

Meconium aspiration occurs when a fetus inhales meconium-stained amniotic fluid. This primarily affects the newborn's respiratory system and does not directly increase the postpartum client's risk of infection. The complications of meconium aspiration are focused on the neonate.

Choice C rationale

A midline episiotomy is a surgical incision made in the perineum during childbirth to enlarge the vaginal opening. This incision creates a break in the skin and mucous membranes, providing a potential portal of entry for bacteria. Therefore, a midline episiotomy places the postpartum client at an increased risk for local infection at the incision site.

Choice D rationale

Gestational hypertension is high blood pressure that develops during pregnancy and typically resolves after delivery. While it poses risks to both the mother and the fetus, it does not directly increase the postpartum client's risk of infection. The primary concerns with gestational hypertension are related to blood pressure control and potential end-organ damage.

A. A client who is at 14 weeks of gestation and reports nausea and vomiting. B. A client who is at 28 weeks of gestation and reports painless vaginal bleeding. C. A client who is at 38 weeks of gestation and reports a cough and fever. D. A client who has missed a period and reports vaginal spotting.

Correct Answer is B

Explanation

Choice A rationale

Nausea and vomiting are common discomforts of pregnancy, particularly in the first trimester. While they can be distressing, they are not typically indicative of an immediate life-threatening condition for the mother or fetus at 14 weeks gestation. Hyperemesis gravidarum, a more severe form, would warrant closer attention, but the description here is general.

Choice B rationale

Painless vaginal bleeding in the second or third trimester (28 weeks gestation) is a concerning sign and could indicate placenta previa or placental abruption, both of which can lead to significant maternal and fetal hemorrhage and compromise fetal oxygenation. This client requires immediate assessment to determine the cause and ensure prompt intervention if necessary.

Choice C rationale

A cough and fever at 38 weeks gestation could indicate an infection, such as influenza or pneumonia. While these conditions can be serious for a near-term pregnant woman and potentially affect the fetus, they are generally less immediately life-threatening than significant vaginal bleeding in the second or third trimester and would be addressed after the client with potential placental issues.

Choice D rationale

Missed period and vaginal spotting can be early signs of pregnancy or a threatened abortion. While it warrants investigation, it is generally not an immediate emergency requiring triage before a client with painless vaginal bleeding at 28 weeks gestation, which carries a higher risk of acute complications.

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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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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.