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The patient has been on IV magnesium sulfate for severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature of 37.3 C, HR 88, RR 9. B/P 140/90, absent deep tendon reflexes, and no ankle clonus. The patient complains, "I am so thirsty and warm," and seems lethargic. The nurse's first action is to:

A.

Call for a STAT magnesium level

B.

Do nothing, this is the expected action of magnesium

C.

Prepare to administer hydralazine

D.

Decrease or Discontinue the magnesium sulfate infusion

Answer and Explanation

The Correct Answer is D

A. Call for a STAT magnesium level. While obtaining a magnesium level is important to confirm magnesium toxicity, the priority action is to stop or reduce the infusion immediately to prevent further toxicity and respiratory depression.

B. Do nothing, this is the expected action of magnesium. Absent deep tendon reflexes, lethargy, and respiratory depression (RR 9) are signs of magnesium toxicity, not expected therapeutic effects. Immediate intervention is necessary to prevent worsening respiratory and cardiac complications.

C. Prepare to administer hydralazine. Hydralazine is used to treat hypertension in preeclampsia, but this patient’s blood pressure is not critically high, and the primary concern is magnesium toxicity, not hypertension. Administering hydralazine would not address the immediate life-threatening issue.

D. Decrease or Discontinue the magnesium sulfate infusion. The first action in magnesium toxicity is to stop or reduce the infusion to prevent further accumulation. If symptoms worsen, calcium gluconate, the antidote for magnesium toxicity, may be administered to reverse its effects, especially if respiratory depression progresses.


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Related Questions

Correct Answer is D

Explanation

A. Apply oxygen. While oxygen may be administered if fetal distress is present, it does not directly resolve shoulder dystocia, which is a mechanical issue requiring immediate positional maneuvers to free the impacted shoulder.

B. Increase IV Pitocin. Increasing oxytocin (Pitocin) is contraindicated in shoulder dystocia because it can cause stronger contractions, worsening the impaction and increasing the risk of fetal injury or uterine rupture.

C. Apply downward pressure on the woman's fundus. Fundal pressure should never be applied in shoulder dystocia, as it can further wedge the fetal shoulder against the pubic bone, increasing the risk of brachial plexus injury and fetal distress.

D. Flex the woman's thighs sharply toward her abdomen. The McRoberts maneuver, which involves sharply flexing the mother’s thighs to widen the pelvic outlet, is the first-line intervention for shoulder dystocia. This maneuver helps rotate the pelvis and reposition the fetal shoulder, increasing the chances of a successful vaginal delivery.

Correct Answer is B

Explanation

While many women are able to get pregnant again after an ectopic pregnancy, it is not guaranteed. The ability to conceive again depends on various factors, such as:

  • The extent of damage to the fallopian tube.

  • Whether one or both tubes are still functional.

  • The treatment used (e.g., methotrexate vs. surgery).

  • Any underlying fertility issues.

It is important to be honest but reassuring, explaining that many women do go on to have healthy pregnancies, but future fertility can be affected and should be discussed with a healthcare provider. Saying she "absolutely will" get pregnant again is inaccurate and potentially misleading.

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