A nurse is caring for a client diagnosed with preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
Assess maternal blood glucose.
Place the client in Trendelenburg position.
Prepare for an emergency cesarean birth.
Discontinue the medication infusion.
The Correct Answer is D
Explanation:
A. Assess maternal blood glucose:
While assessing blood glucose levels is important in clients receiving magnesium sulfate due to its potential effects on blood sugar, it is not the priority action in this scenario. The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular effects. Therefore, the immediate concern is addressing the magnesium toxicity rather than assessing blood glucose levels.
B. Place the client in Trendelenburg position:
Placing the client in Trendelenburg position is not indicated for magnesium toxicity. The Trendelenburg position involves placing the client in a supine position with the legs elevated higher than the head. While this position may be used in some situations (e.g., hypotension), it is not appropriate for treating magnesium toxicity, respiratory depression, or absent deep-tendon reflexes. Placing the client in Trendelenburg position may worsen respiratory function and is not recommended in this case.
C. Prepare for an emergency cesarean birth:
While severe preeclampsia or eclampsia may necessitate emergency cesarean birth in some cases, it is not the immediate action needed for a client experiencing respiratory depression and absent deep-tendon reflexes due to magnesium sulfate toxicity. Cesarean birth is not the appropriate response to magnesium toxicity and would not address the client's current respiratory and neuromuscular issues. Therefore, preparing for an emergency cesarean birth is not the correct action in this scenario.
D. Discontinue the medication infusion:
This is the correct action to take. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Magnesium sulfate, while effective in preventing seizures in preeclampsia, can lead to respiratory depression and affect neuromuscular function at toxic levels. Discontinuing the medication infusion is crucial to prevent further magnesium toxicity and adverse effects on the client's respiratory and neuromuscular status. It is the immediate and priority action needed to address the client's current condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Explanation:
A. Rh incompatibility
Amniocentesis is not used to identify Rh incompatibility. Rh incompatibility occurs when the mother is Rh-negative, and the baby is Rh-positive, leading to potential complications if the mother develops antibodies against the baby's Rh-positive blood cells. However, this condition is typically managed through other means such as Rh immunoglobulin (RhIg) administration.
B. Fetal gender
Amniocentesis can determine the fetal gender by analyzing the chromosomes present in the fetal cells obtained from the amniotic fluid. The presence of a Y chromosome indicates a male fetus, while its absence indicates a female fetus. Therefore, fetal gender can be identified through amniocentesis.
C. Cephalopelvic disproportion
Cephalopelvic disproportion refers to a situation where the baby's head is too large to pass through the mother's pelvis during childbirth. This condition is typically diagnosed during labor based on the progress of labor and fetal descent. Amniocentesis is not used to identify cephalopelvic disproportion.
D. Anomalies in fetal chromosomes
Amniocentesis is primarily used to identify anomalies in fetal chromosomes, such as chromosomal abnormalities like Down syndrome (Trisomy 21), Trisomy 18, and Trisomy 13. It can also detect other chromosomal abnormalities and genetic disorders caused by changes in the number or structure of chromosomes.
E. Neural tube defects
Amniocentesis can detect neural tube defects, such as spina bifida and anencephaly, by analyzing levels of alpha-fetoprotein (AFP) and other markers in the amniotic fluid. Elevated levels of AFP may indicate a neural tube defect.
Correct Answer is C
Explanation
Explanation:
A. Pattern of contractions: While the pattern of contractions is important in assessing labor progress, it alone may not differentiate between true labor and false labor (also known as Braxton Hicks contractions). True labor contractions typically become longer, stronger, and more frequent over time, but other factors must also be considered to confirm true labor.
B. Rupture of the membranes: Rupture of the membranes (water breaking) can occur during both true labor and false labor. However, it is not a definitive sign of true labor on its own, as it can also happen spontaneously or due to other reasons.
C. Changes in the cervix: This is the correct answer. True labor is characterized by progressive changes in the cervix, including effacement (thinning) and dilation (opening). These changes can be confirmed through a cervical examination performed by a healthcare provider.
D. Station of the presenting part: The station of the presenting part refers to the position of the baby's head in relation to the mother's pelvis. While the station can provide information about the progress of labor, it is not a specific sign of true labor by itself.
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