A nurse is caring for a client who has eclampsia and is receiving magnesium sulfate and hydralazine.
The client’s blood pressure is 150/90 mmHg, pulse is 88/min, respirations are 18/min, and oxygen saturation is 97%.
The nurse notes that the client’s deep tendon reflexes are absent.
Which of the following actions should the nurse take?
Stop the magnesium sulfate infusion
Increase the rate of the hydralazine infusion
Administer calcium gluconate IV push
Prepare for immediate delivery of the fetus
The Correct Answer is A
Stop the magnesium sulfate infusion.
The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.
Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.
The nurse should stop the infusion and monitor the client’s vital signs and neurological status.
Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.
The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.
Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.
It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.
Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.
The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.
Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Respiratory rate of 10 breaths/minute.This indicates that the client is experiencingmagnesium toxicity, which can causemuscle weakness,difficulty breathing, andcardiac arrest.The normal respiratory rate for adults is 12 to 20 breaths/minute.
Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.
Choice C is wrong because urinary output of 40 mL/hour is within the normal range of 30 to 50 mL/hour.Magnesium toxicity can cause urine retention, not increased output.
Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L.Magnesium toxicity occurs when the level is above 2.6 mEq/L.
Correct Answer is A
Explanation
Headache that does not respond to analgesics.This is a possible sign of postpartum pre-eclampsia, a rare condition that occurs when a woman has high blood pressure and excess protein in her urine soon after childbirth.Postpartum pre-eclampsia can cause seizures and other serious complications if not treated.
Choice B is wrong because breast engorgement and tenderness are normal symptoms of breastfeeding and do not indicate postpartum pre-eclampsia.
Choice C is wrong because lochia rubra with small clots is a normal discharge of blood and tissue from the uterus after delivery and does not indicate postpartum pre-eclampsia.
Choice D is wrong because perineal pain and swelling are common after vaginal delivery and do not indicate postpartum pre-eclampsia.
Normal ranges for blood pressure are below 120/80 mm Hg and for protein in urine are below 150 mg/day.
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