A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?
Assess maternal blood glucose.
Discontinue the magnesium infusion.
Prepare for an emergency cesarean birth.
Place the client in Trendelenburg position.
The Correct Answer is B
Choice A reason:
Assessing maternal blood glucose is important in various clinical scenarios, such as managing diabetes during pregnancy. However, it is not directly related to the immediate issue of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min is a critical sign that requires immediate intervention to prevent further complications.
Choice B reason:
Discontinuing the magnesium infusion is the priority intervention. Magnesium sulfate toxicity can lead to severe respiratory depression, hypotension, and loss of deep tendon reflexes. A respiratory rate of 10/min indicates significant respiratory depression, which can be life-threatening. Stopping the infusion immediately helps to prevent further accumulation of magnesium in the body and allows for the administration of the antidote, calcium gluconate, if necessary.
Choice C reason:
Preparing for an emergency cesarean birth is a critical intervention in cases of fetal distress or other obstetric emergencies. However, in this scenario, the immediate concern is the client’s respiratory depression due to magnesium sulfate toxicity. Addressing the respiratory issue takes precedence to stabilize the client before considering any surgical interventions.
Choice D reason:
Placing the client in Trendelenburg position is typically used to treat hypotension or shock by promoting venous return to the heart. While it can be beneficial in certain situations, it does not address the primary issue of respiratory depression caused by magnesium sulfate toxicity. The priority is to discontinue the magnesium infusion and manage the respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
The presence of 3+ protein in the urine is consistent with preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, indicating kidney involvement and damage. High levels of protein in the urine are a common finding in patients with preeclampsia.
Choice B Reason:
Deep tendon reflexes of 1+ are inconsistent with preeclampsia. Preeclampsia often causes hyperreflexia, which means increased reflex responses. Typically, patients with preeclampsia exhibit brisk reflexes (3+ or 4+), which can be a sign of central nervous system irritability and an increased risk of seizures.
Choice C Reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. Preeclampsia is characterized by high blood pressure, defined as systolic blood pressure of 140 mm Hg or higher, or diastolic blood pressure of 90 mm Hg or higher, measured on two occasions at least four hours apart.
Choice D Reason:
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the lower extremities and sacral area, is a common symptom of preeclampsia due to increased capillary permeability and fluid retention.
Correct Answer is ["C","D"]
Explanation
Choice A reason:
“Small for gestational age” (SGA) refers to babies who are smaller than the typical weight for their gestational age, usually below the 10th percentile. An 8-pound 15-ounce baby born at 35 weeks is not considered SGA because this weight is above the average for that gestational age
Choice B reason:
“Term” refers to babies born between 37 and 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered term.
Choice C reason:
“Preterm” refers to babies born before 37 weeks of gestation. A baby born at 35 weeks falls into this category and is specifically classified as a “late preterm” infant3. Late preterm infants are those born between 34 and 36 weeks of gestation. These babies may require additional medical support compared to full-term infants but generally have better outcomes than those born earlier.
Choice D reason:
“Average for gestational age” (AGA) refers to babies whose weight is within the normal range for their gestational age, typically between the 10th and 90th percentiles. An 8-pound 15-ounce baby born at 35 weeks is considered AGA because this weight is within the expected range for that gestational age.
Choice E reason:
“Post term” refers to babies born after 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered post term.
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