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 D
Explanation
Explanation:
A. This test assesses fetal lung maturity.
The explanation provided is incorrect. The maternal serum alpha-fetoprotein (MSAFP) test is not used to assess fetal lung maturity. Fetal lung maturity is typically assessed through tests such as amniocentesis, which evaluates factors like the lecithin-to-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) levels in amniotic fluid.
B. This test identifies an Rh incompatibility between the mother and fetus.
The explanation provided is also incorrect. The MSAFP test is not used to identify Rh (Rhesus) incompatibility between the mother and fetus. Rh incompatibility is determined through other tests, such as blood typing (Rh factor) and antibody screening.
C. It assesses various markers of fetal well-being.
This explanation is not accurate. While the MSAFP test does provide information about certain fetal abnormalities, it is primarily used as a screening test for neural tube defects (spinal defects) and abdominal wall defects rather than assessing overall fetal well-being, which involves a comprehensive evaluation of various fetal parameters.
D. It is a screening test for spinal defects in the fetus.
This explanation is correct. The MSAFP test is indeed a screening test specifically used to assess the risk of spinal defects, also known as neural tube defects, in the fetus. These defects include conditions such as spina bifida. The test measures the levels of alpha-fetoprotein in the mother's blood to screen for these abnormalities during pregnancy.
Correct Answer is B
Explanation
Explanation:
A. The biparietal diameter
The biparietal diameter is a measurement of the fetal head's diameter, which is often assessed during routine prenatal ultrasounds to estimate gestational age and monitor fetal growth. However, in the scenario described, the client is experiencing heavy vaginal bleeding without contractions at 38 weeks of gestation. The focus is on the immediate concern of the fetus's well-being rather than assessing specific fetal measurements like the biparietal diameter.
B. Viability of the fetus
This choice is correct for the scenario described. Viability refers to the ability of the fetus to survive outside the uterus. Heavy vaginal bleeding near term raises concerns about potential harm to the fetus and its viability. An ultrasound would be performed to assess the fetal heart rate, movement, and overall condition to determine if the fetus is viable or if there are any immediate concerns that need to be addressed.
C. Fetal lung maturity
Fetal lung maturity is typically assessed closer to the end of pregnancy, usually around 36 to 39 weeks of gestation, to determine if the fetus's lungs are developed enough for birth. While important for planning deliveries, assessing fetal lung maturity is not the primary concern in a situation where the client is experiencing heavy vaginal bleeding without contractions at 38 weeks of gestation.
D. Location of the placenta
The location of the placenta is important for monitoring placental health and assessing potential complications such as placenta previa. However, in the context of heavy vaginal bleeding without contractions at 38 weeks of gestation, the immediate concern is the well-being and viability of the fetus rather than the placental location.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today