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.)
Check the client’s blood pressure
Check the client’s pulse oximetry
Check the client’s reflexes
Check the client’s urine specific gravity
Check the client’s magnesium level
Correct Answer : A,E
The correct answer is choice A and E. The nurse should check the client’s blood pressure and magnesium level before giving hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
• Choice A is correct because hydralazine is an antihypertensive drug that lowers blood pressure by relaxing blood vessels. The nurse should monitor the client’s blood pressure before and after giving hydralazine to ensure that it is within the target range and to avoid hypotension or rebound hypertension.
• Choice B is wrong because pulse oximetry is not directly related to hydralazine administration or pre-eclampsia. Pulse oximetry measures the oxygen saturation of hemoglobin in the blood and can be affected by factors such as anemia, hypothermia, nail polish, or movement.
The nurse should monitor the client’s pulse oximetry as part of routine care, but it is not a priority before giving hydralazine.
• Choice C is wrong because checking the client’s reflexes is not directly related to hydralazine administration or pre-eclampsia. Reflexes are assessed to monitor for signs of magnesium toxicity, which can cause muscle weakness, respiratory depression, and cardiac arrest.
The nurse should check the client’s reflexes as part of routine care, but it is not a priority before giving hydralazine.
• Choice D is wrong because checking the client’s urine specific gravity is not directly related to hydralazine administration or pre-eclampsia. Urine specific gravity measures the concentration of solutes in the urine and can be affected by factors such as hydration status, renal function, or diuretic use.
The nurse should monitor the client’s urine specific gravity as part of routine care, but it is not a priority before giving hydralazine.
• Choice E is correct because magnesium sulfate is a drug that prevents and treats seizures in women with severe pre-eclampsia or eclampsia. The nurse should monitor the client’s magnesium level before and after giving magnesium sulfate to ensure that it is within the therapeutic range and to avoid magnesium toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["C","E"]
Explanation
The correct answer is choice C and E.A platelet count of 100,000/mm3 is low and indicates a risk of bleeding due to preeclampsia.A urine output of 20 mL/hour is also low and suggests kidney impairment due to magnesium sulfate therapy.
Both of these results should be reported to the provider as they may require intervention.
Choice A is wrong because a serum creatinine of 1.2 mg/dL is within the normal range of 0.6 to 1.3 mg/dL for womenand does not indicate kidney dysfunction.
Choice B is wrong because liver enzymes of 40 U/L are within the normal range of 7 to 55 U/L for women and do not indicate liver damage.
Choice D is wrong because a coagulation profile of 12 seconds is within the normal range of 11 to 13.5 seconds for women and does not indicate a clotting disorder.
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