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. Placenta previa: Placenta previa is a condition where the placenta partially or completely covers the cervix. Painless, bright red vaginal bleeding is a common symptom of placenta previa, especially in the third trimester. This bleeding occurs because the placental blood vessels are disrupted as the cervix begins to dilate or efface during pregnancy.

B. Abruptio placentae: Abruptio placentae is a condition where the placenta detaches from the uterine wall prematurely, leading to painful bleeding. However, the bleeding associated with abruptio placentae is typically dark red and accompanied by uterine pain or contractions. In the scenario described, the bleeding is painless, making abruptio placentae less likely.

C. Threatened abortion: Threatened abortion refers to vaginal bleeding during early pregnancy (before 20 weeks) that may or may not be accompanied by cramping or abdominal pain. It is not typically associated with painless, bright red bleeding at 36 weeks gestation.

D. Precipitous labor: Precipitous labor refers to a rapid labor and delivery process, often completing in less than three hours from onset of contractions to delivery. It is not related to painless, bright red vaginal bleeding.

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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