The parents of a newborn with a small ventricular septal defect (VSD) are concerned about the prognosis for their child. Which information should the nurse provide the parents?

Choice A rationale

A blood pressure of 167/107 mm Hg is classified as severe hypertension. This is an urgent and potentially life-threatening condition that requires immediate attention, not routine monitoring. Documenting the findings is part of the process, but it is insufficient as a standalone action. Delaying intervention could lead to eclampsia, stroke, or other serious complications.

Choice B rationale

Administering a prescribed antihypertensive medication is a likely intervention, but it is not the most appropriate initial nursing action without first notifying the healthcare provider. The nurse must communicate the critical change in the client's status to the provider to receive specific orders for medication, dosage, and subsequent monitoring based on the clinical picture.

Choice C rationale

A blood pressure of 167/107 mm Hg is indicative of a hypertensive crisis. The most appropriate and immediate nursing action is to notify the healthcare provider. This allows for a timely, coordinated response, including the potential for medication orders, further diagnostic tests, and a change in the plan of care to prevent an eclamptic seizure, stroke, or other end-organ damage.

Choice D rationale

While increasing the frequency of vital sign measurements is an important part of managing severe hypertension, it is not the most appropriate initial action. The primary action is to notify the healthcare provider. The provider will then likely order more frequent monitoring. The nurse must first report the critical finding to initiate the appropriate medical response.

Choice A rationale

Magnesium sulfate is a central nervous system depressant that can cause toxicity, especially at therapeutic levels used in preeclampsia treatment. Signs of toxicity include a decrease in deep tendon reflexes, somnolence, and respiratory depression. Stopping the infusion is the primary intervention to prevent further neurological and respiratory compromise.

Choice B rationale

Magnesium toxicity can depress the respiratory center in the brainstem, leading to hypoventilation and potential respiratory arrest. It can also cause cardiac conduction delays, leading to bradycardia and potentially cardiac arrest. Preparing for these critical events is essential for prompt resuscitation and airway management if they occur.

Choice E rationale

Respiratory depression is a major concern with magnesium toxicity due to its central nervous system depressant effects on the medullary respiratory centers. Administering oxygen helps to counteract hypoxemia, which can result from decreased respiratory effort. It supports tissue oxygenation and mitigates the risk of organ damage.

Choice G rationale

A serum magnesium level is the definitive diagnostic tool for confirming magnesium toxicity. The normal therapeutic range is 4-7 mEq/L. Levels above 8-12 mEq/L are associated with loss of deep tendon reflexes, while levels above 12-15 mEq/L are associated with respiratory paralysis. Obtaining a level guides further treatment decisions.

Choice H rationale

Calcium gluconate is the physiological antagonist to magnesium at the cellular level. It rapidly reverses the neuromuscular and cardiac depressant effects of hypermagnesemia by competing for binding sites on the cell membrane, which helps restore nerve conduction and muscle contraction. It is the immediate antidote for severe magnesium toxicity.