A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
Difficulty in arousing
Deep tendon reflexes 2+
Urinary output of 30 mL per hour
Respiratory rate of 10 breaths/minute
The Correct Answer is B
Choice A Reason: This is incorrect because difficulty in arousing is a sign of magnesium toxicity, which is a serious complication of magnesium sulfate therapy. Magnesium toxicity can cause central nervous system depression, muscle weakness, and cardiac arrest. The nurse should monitor the client's level of consciousness and stop the infusion if the client becomes lethargic or unresponsive.
Choice B Reason: This is correct because deep tendon reflexes 2+ indicate a normal and expected response to magnesium sulfate therapy. Magnesium sulfate is a muscle relaxant that can reduce the risk of seizures in gestational hypertension. The nurse should assess the client's deep tendon reflexes regularly and maintain them at 2+ or slightly diminished.
Choice C Reason: This is incorrect because urinary output of 30 mL per hour is below the normal range of 40 to 80 mL per hour and may indicate renal impairment or dehydration. Magnesium sulfate can cause renal toxicity or fluid retention, which can affect the urinary output. The nurse should monitor the client's urinary output and fluid balance and report any abnormalities to the doctor.
Choice D Reason: This is incorrect because respiratory rate of 10 breaths/minute is below the normal range of 12 to 20 breaths/minute and may indicate respiratory depression. Magnesium sulfate can cause respiratory depression or failure, which can be life-threatening. The nurse should monitor the client's respiratory rate and oxygen saturation and administer oxygen or antidote if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This option is incorrect because it is unrealistic and impractical to eliminate anxiety completely. Anxiety is a normal and natural response to pregnancy and childbirth, and it can have both positive and negative effects on the outcome. Anxiety can motivate women and their partners to seek information and care, but it can also interfere with their ability to relax and cope with pain. Perinatal education can help them manage their anxiety by providing accurate information, reassurance, and coping strategies.
Choice B Reason: This option is incorrect because it implies that the couple has no control over their pregnancy and birth unless they are empowered by perinatal education. While perinatal education can enhance their sense of control and autonomy, it is not the only factor that influences their experience. Pregnancy and birth are complex and dynamic processes that involve many factors beyond their control, such as biological, environmental, social, and cultural factors. Perinatal education can help them adapt to these factors and collaborate with their health care providers.
Choice C Reason: Perinatal education is a process of providing information and support to pregnant women and their partners before, during, and after childbirth. The main goal of perinatal education is to help them prepare for a positive birth experience, which can have lasting benefits for their physical and emotional health, as well as their relationship with their baby. Perinatal education can also help them make informed decisions about their care and preferences, and cope with any challenges or complications that may arise.
Choice D Reason: This option is incorrect because it is too narrow and limited in scope. Providing knowledge and skills that will help them cope with labor is an important aspect of perinatal education, but it is not the primary goal. Labor is only one stage of childbirth, and perinatal education covers a broader range of topics that are relevant for pregnancy, birth, and postpartum. Moreover, coping with labor is not the only outcome that matters for a positive birth experience. Perinatal education can also help them achieve other outcomes, such as satisfaction, empowerment, bonding, and well-being.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because administering Rho(D) immune globulin 24 hours before delivery is too early and may not provide adequate protection for the fetus. Administering it 24 hours after delivery is too late and may not prevent the mother from developing antibodies against the fetal Rh-positive blood cells.
Choice B Reason: This is incorrect because administering Rho(D) immune globulin in the first trimester is unnecessary and may not be effective, as the risk of Rh isoimmunization is very low before 28 weeks of gestation. Administering it within 2 hours of delivery is appropriate, but not sufficient, as it should be repeated within 72 hours after delivery.
Choice C Reason: This is correct because administering Rho(D) immune globulin at 28 weeks gestation and again within 72 hours after delivery is the recommended schedule for preventing Rh isoimmunization in Rh-negative pregnant women who have Rh-positive partners. This regimen can prevent up to 99% of cases of Rh isoimmunization by blocking the maternal immune response to the fetal Rh-positive blood cells.
Choice D Reason: This is incorrect because administering Rho(D) immune globulin at 32 weeks gestation is too late and may not prevent Rh isoimmunization if there has been any fetal-maternal hemorrhage before that time. Administering it immediately before discharge is also too late and may not prevent the mother from developing antibodies against the fetal Rh-positive blood cells.
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