A nurse is caring for a client who has 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?

Prepare for an emergency cesarean birth.

Discontinue the medication infusion.

Place the client in Trendelenburg's position.

Assess maternal blood glucose.

Answer and Explanation

The Correct Answer is B

Choice A) Prepare for an emergency cesarean birth is incorrect because this is not a priority or appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.

Preeclampsia is a condition that causes high blood pressure, proteinuria, and edema during pregnancy. It can lead to complications such as eclampsia, which is seizures, or HELLP syndrome, which is hemolysis, elevated liver enzymes, and low platelets. Magnesium sulfate is a medication that helps to prevent or treat seizures in preeclamptic clients by relaxing the muscles and nerves. However, it can also cause side effects such as respiratory depression, hypotension, or loss of reflexes. Preparing for an emergency cesarean birth may be necessary if the client has severe preeclampsia or fetal distress, but it does not address the immediate problem of magnesium toxicity. Therefore, this action should be done only when indicated by the physician and after stabilizing the client's condition.

Choice B) Discontinue the medication infusion is correct because this is a priority and appropriate action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Discontinuing the medication infusion can help to stop or reduce the adverse effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. These effects can indicate magnesium toxicity, which is a life-threatening condition that can cause cardiac arrest or coma. The nurse should also notify the physician and prepare to administer calcium gluconate, which is an antidote for magnesium toxicity. Therefore, this action should be done as soon as possible for clients who show signs of magnesium overdose.

Choice C) Place the client in Trendelenburg's position is incorrect because this is not a safe or suitable action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV.

Trendelenburg's position means lying on the back with the head lower than the feet. It is sometimes used to improve blood flow to the brain or heart in cases of shock or hypotension. However, it can also cause complications such as increased intracranial pressure, decreased lung expansion, aspiration, or acid reflux. Moreover, it does not help to reverse or prevent the side effects of magnesium sulfate, such as respiratory depression, hypotension, or loss of reflexes. Therefore, this action should be avoided or used with caution for clients who are receiving magnesium sulfate IV.

Choice D) Assess maternal blood glucose is incorrect because this is not a relevant or necessary action for a nurse who is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. Blood glucose is the level of sugar in the blood that provides energy to the cells. It is measured by a blood test or a finger stick test. It can be affected by various factors such as diet, exercise, medication, or pregnancy. Assessing maternal blood glucose may be important for clients who have diabetes or gestational diabetes, which are conditions that cause high blood sugar levels that can harm the mother and the baby. However, it does not relate to preeclampsia or magnesium sulfate, which are conditions that affect blood pressure and nerve function. Therefore, this action should be done only when indicated by the physician and according to the client's history and needs.

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Correct Answer is C

Explanation

Choice A: This is incorrect because preeclampsia is a condition characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is not related to abruptio placentae, which is the premature separation of the placenta from the uterine wall. Preeclampsia does not cause petechiae or bleeding around the IV site, but it may cause headache, blurred vision, epigastric pain, or seizures.

Choice B: This is incorrect because anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare and life-threatening complication that occurs when amniotic fluid enters the maternal circulation and triggers an allergic reaction. It is not related to abruptio placentae, but it may occur during labor, delivery, or shortly after birth. Anaphylactoid syndrome of pregnancy does not cause petechiae or bleeding around the IV site, but it may cause respiratory distress, hypotension, cardiac arrest, or disseminated intravascular coagulation.

Choice C: This is the correct answer because disseminated intravascular coagulation (DIC) is a condition in which the blood clotting system is activated abnormally, leading to excessive clot formation and consumption of clotting factors and platelets. This results in bleeding from various sites, such as the IV site, gums, nose, or vagina. DIC is a common complication of abruptio placentae, as the release of thromboplastin from the placenta triggers the clotting cascade. DIC can also cause organ failure, shock, or death if not treated promptly.

Choice D: This is incorrect because puerperal infection, also known as postpartum infection, is a bacterial infection that affects the uterus, vagina, bladder, or wound site after childbirth. It is not related to abruptio placentae, but it may occur due to prolonged labor, cesarean delivery, retained placenta, or poor hygiene. Puerperal infection does not cause petechiae or bleeding around the IV site, but it may cause fever, malaise, foul-smelling lochia, or pelvic pain.

A. Have the parent fold the infant's arms across the chest. B. Encourage the parent to place the infant back in the warmer. C. Encourage the parent to do kangaroo care. D. Cover the infant with a warm bed blanket.

Correct Answer is C

Explanation

Choice a) Have the parent fold the infant's arms across the chest is incorrect because this is not a helpful way to calm a preterm infant. Folding the arms across the chest can restrict the infant's breathing and movement, and may increase their stress and discomfort. Preterm infants need gentle and supportive touch, not restraint or pressure.

Choice b) Encourage the parent to place the infant back in the warmer is incorrect because this is not a necessary or beneficial action for a preterm infant who is showing signs of overstimulation. Placing the infant back in the warmer can interrupt the bonding and attachment process between the parent and the infant, and may make the infant feel more isolated and insecure. Preterm infants need close and frequent contact with their parents, not separation or detachment.

Choice c) Encourage the parent to do kangaroo care is correct because this is an effective and evidence-based method of soothing and stabilizing a preterm infant who is experiencing overstimulation. Kangaroo care is a technique where the parent holds the infant skin-to-skin on their chest, providing warmth, comfort, and security. Kangaroo care can reduce the infant's stress hormones, lower their heart rate and blood pressure, improve their oxygenation and breathing, enhance their growth and development, and strengthen their bond with their parent.

Choice d) Cover the infant with a warm bed blanket is incorrect because this is not a sufficient or optimal way to comfort a preterm infant who is displaying signs of overstimulation. Covering the infant with a warm bed blanket can provide some warmth and protection, but it does not offer the same benefits as kangaroo care. A warm bed blanket cannot mimic the parent's heartbeat, voice, smell, and movement, which are essential for the infant's emotional and physiological well-being. Preterm infants need human touch and interaction, not just physical warmth.

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A nurse is caring for a client who has 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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Correct Answer is C

Explanation

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