A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 98.1F, pulse rate of 96 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 135/90 mm Hg, 1+ deep tendon reflexes, and not ankle clonus. The nurse calls the physician, anticipating an order for:
Select one:
Diazepam.
Hydralazine orally twice a day.
Calcium Gluconate
Second bolus of Magnesium sulfate.
The Correct Answer is C
a. Diazepam is not indicated for the treatment of severe preeclampsia.
b. Hydralazine orally twice a day is not indicated for the treatment of severe preeclampsia.
c. Calcium Gluconate is indicated for the treatment of hypermagnesemia, which can occur as a result of magnesium sulfate infusion.
d. This will worsen the magnesium toxicity.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. This may be done if the fetal heart rate (FHR) tracing is not clear, but it is not the first priority in this situation.
b. Early decelerations can indicate fetal head compression and is a normal finding hence there is no need of notifying the healthcare provider.
c. One of the FHR patterns that may be observed is early decelerations, which are symmetrical decreases in FHR that coincide with uterine contractions. Early decelerations are usually benign and reflect fetal head compression during contractions. The nurse's first priority in this case is to document as a normal finding and continue to monitor the FHR and uterine activity.
d. This may help relieve pressure on the fetal head and improve FHR, but it is not the first priority in this situation.
Correct Answer is A
Explanation
a. Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy that occurs around the time of implantation of the fertilized egg.
b. A positive pregnancy test is a probable sign of pregnancy that can occur as early as 7-10 days after conception.
c. Chadwick's sign, or the bluish discoloration of the cervix and vagina, is a probable sign of pregnancy that typically occurs around 6-8 weeks of gestation.
d. Hegar's sign, or the softening of the lower uterine segment, is a probable sign of pregnancy that typically occurs around 6-12 weeks of gestation.
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