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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Explanation:

A. "This will occur between the fourth and fifth months of pregnancy."

This response is accurate and aligns with the typical timeframe for quickening, which is the first perception of fetal movements by the pregnant person. Quickening commonly occurs between the 16th and 20th week of pregnancy, corresponding to the fourth and fifth months. However, it's essential to note that the exact timing can vary from person to person and pregnancy to pregnancy.

B. "This will happen by the end of the first trimester of pregnancy."

This response is not entirely accurate. Quickening typically occurs later than the end of the first trimester. While some women, particularly those who have been pregnant before, may feel fetal movements toward the end of the first trimester, it's more common to experience quickening during the second trimester.

C. "This will happen once the uterus begins to rise out of the pelvis."

This response is not directly related to quickening. The rising of the uterus (fundus) out of the pelvic cavity is a physical change that occurs as the pregnancy progresses, but it doesn't signify the onset of fetal movements (quickening). Quickening is specifically about feeling the baby's movements, not the position of the uterus.

D. “This will occur during the last trimester of pregnancy."

This response is incorrect. Quickening typically occurs much earlier, specifically during the second trimester, around the 16th to 20th week of pregnancy. Waiting until the last trimester to feel fetal movements would be unusual and might prompt further evaluation or discussion with a healthcare provider.

A. Limit alcohol consumption. B. Consume foods fortified with folic acid. C. Increase intake of iron-rich foods. D. Avoid foods containing aspartame.

Correct Answer is B

Explanation

Explanation:

A. Limit alcohol consumption:

Alcohol consumption during pregnancy is associated with various risks, including fetal alcohol spectrum disorders (FASDs). However, in the context of reducing the risk of NTDs specifically, the focus is on nutritional factors, particularly folic acid intake, rather than alcohol consumption.

B. Consume foods fortified with folic acid:

This choice is the correct recommendation. Folic acid is crucial for the prevention of neural tube defects. Women of childbearing age, especially those planning pregnancy, are advised to consume foods fortified with folic acid or take folic acid supplements to ensure adequate intake before and during early pregnancy. This is a key preventive measure endorsed by healthcare professionals worldwide.

C. Increase intake of iron-rich foods:

Iron is important during pregnancy to prevent anemia and support fetal growth and development. However, iron intake is not directly linked to reducing the risk of neural tube defects. While overall nutritional health is essential during pregnancy, focusing on iron-rich foods alone does not specifically address the prevention of NTDs.

D. Avoid foods containing aspartame:

Aspartame is an artificial sweetener found in many foods and beverages. While there may be general recommendations regarding artificial sweetener consumption during pregnancy, avoiding foods with aspartame is not directly related to reducing the risk of neural tube defects. The primary focus for NTD prevention lies in adequate folic acid intake.

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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?

Nursing Test Bank

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