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 C
Explanation
Explanation:
A. "You will need to double your intake of iron during pregnancy."
This statement is not accurate. While iron needs do increase during pregnancy to support the increased blood volume and fetal development, the recommended increase is not necessarily a doubling of intake. Specific iron requirements can vary based on individual factors, such as pre-pregnancy iron status and maternal health conditions.
B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy."
Prenatal vitamins typically contain some vitamin D, but they may not meet the increased need for vitamin D during pregnancy entirely, especially if the client has limited sun exposure or other risk factors for vitamin D deficiency. Additional sources of vitamin D, such as sunlight exposure and dietary sources, may be recommended.
C. "You will need to increase your calcium intake during breastfeeding."
This statement is correct. During breastfeeding, calcium requirements increase to support milk production and the maintenance of maternal bone health. Adequate calcium intake is important for both the mother and the growing infant.
D. "Vitamin E requirements decline during pregnancy due to the increase in body fat."
This statement is not accurate. Vitamin E requirements do not necessarily decline during pregnancy because of an increase in body fat. Vitamin E is still essential during pregnancy for its antioxidant properties and role in fetal development.
Correct Answer is D
Explanation
Explanation:
A. "This is a probable sign of pregnancy."
A probable sign of pregnancy is an objective finding observed by a healthcare provider that suggests the likelihood of pregnancy but does not confirm it definitively. Examples of probable signs include positive pregnancy tests (urine or blood tests), changes in the uterus (enlargement, softening), and changes in the cervix (Goodell's sign, Chadwick's sign). Sensations of fetal movement, such as the feeling of the baby moving, are actually presumptive signs of pregnancy rather than probable signs because they can have other explanations and are not definitive proof of pregnancy.
B. "This is a possible sign of pregnancy."
While sensations of fetal movement can be associated with pregnancy, they are more accurately classified as presumptive signs rather than possible signs. Possible signs typically refer to signs or symptoms that could be related to various conditions, including pregnancy, but do not specifically indicate pregnancy on their own. In this context, "possible" may not be as accurate as "presumptive" for describing fetal movement as a sign of pregnancy.
C. "This is a positive sign of pregnancy."
A positive sign of pregnancy is a definitive finding that confirms the presence of a fetus. Examples of positive signs include fetal heartbeat heard by Doppler or ultrasound, fetal movement felt by the healthcare provider (palpation), and visualization of the fetus on ultrasound. Sensations of fetal movement reported by the woman (quickening) are not considered positive signs because they can be subjective and may have other explanations, such as gas or muscle contractions.
D. "This is a presumptive sign of pregnancy."
A presumptive sign of pregnancy is a subjective sign reported by the woman that may indicate pregnancy but can also have other explanations. Examples include amenorrhea (missed periods), nausea and vomiting (morning sickness), breast changes, and sensations of fetal movement (quickening). Sensations of fetal movement are considered presumptive because they are subjective and can be caused by factors other than pregnancy, such as gas or muscle contractions.

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