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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A) "Oh, don't worry about that. It's okay." is incorrect because this is not a helpful or informative response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not explain what the black, sticky stuff in the diaper is, why it is there, or how long it will last. It also does not address the father's concern or curiosity, and may make him feel dismissed or ignored. Therefore, this response is inadequate and inappropriate.
Choice B) "That's meconium, which is your baby's first stool. It's normal." is correct because this is a clear and accurate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response explains what the black, sticky stuff in the diaper is, which is meconium. Meconium is a substance that consists of amniotic fluid, mucus, bile, and other waste products that accumulate in the baby's intestines before birth. It is usually passed within the first 24 to 48 hours after birth, and then replaced by transitional or regular stools. Meconium has a dark green or black color and a thick, sticky consistency. It does not have any odor or bacteria. It is normal and harmless for most babies, unless they inhale it during delivery, which can cause breathing problems or infection. Therefore, this response reassures and educates the father about his baby's condition.
Choice C) "That's transitional stool." is incorrect because this is not a true or complete response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not identify what the black, sticky stuff in the diaper is, which is meconium. Transitional stool is a type of stool that appears after meconium and before regular stools. It usually occurs between the second and fifth day after birth, and then changes to yellow or brown stools. Transitional stool has a greenish-brown color and a loose, seedy consistency. It may have some odor or bacteria. It indicates that the baby's digestive system is maturing and adapting to breast milk or formula. Therefore, this response confuses and misleads the father about his baby's condition.
Choice D) "That means your baby is bleeding internally." is incorrect because this is not a valid or appropriate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not describe what the black, sticky stuff in the diaper is, which is meconium. Bleeding internally means that blood vessels are damaged or ruptured inside the body, causing blood loss and shock. This can be caused by various factors such as trauma, infection, clotting disorder, or medication. Bleeding internally can manifest as blood in the stool, urine, vomit, or saliva. However, it does not cause black, sticky stools like meconium. Moreover, this response scares and alarms the father without any evidence or reason. Therefore, this response is false and unethical.
Correct Answer is D
Explanation
Choice a) Ectopic pregnancy is incorrect because this is not a condition that requires delivery by cesarean section. Ectopic pregnancy is a condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. It is a life-threatening complication that can cause internal bleeding and rupture of the tube. Ectopic pregnancy cannot result in a viable baby and must be terminated as soon as possible, either by medication or surgery. Therefore, this response is irrelevant and inaccurate.
Choice b) Preeclampsia is incorrect because this is not a condition that always necessitates delivery by cesarean section. Preeclampsia is a condition where the blood pressure rises above 140/90 mmHg after 20 weeks of pregnancy, along with proteinuria and edema. It can cause complications such as eclampsia, HELLP syndrome, placental abruption, and fetal growth restriction. The only cure for preeclampsia is delivery of the baby and placenta, but the mode of delivery depends on several factors, such as the gestational age, the severity of the condition, the fetal status, and the maternal preference. Therefore, some women with preeclampsia may deliver vaginally, while
others may need a cesarean section.
Choice c) Partial abruptio placentae is incorrect because this is not a condition that always necessitates delivery by cesarean section. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, causing vaginal bleeding, abdominal pain, uterine contractions, and fetal distress. It can be classified as partial or complete, depending on the extent of the separation. The mode of delivery for abruptio placentae depends on several factors, such as the degree of bleeding, the fetal viability, the cervical dilation, and the fetal position.
Therefore, some women with partial abruptio placentae may deliver vaginally, while others may need a cesarean section.
Choice d) Total placenta previa is correct because this is the only condition that always necessitates delivery by cesarean section. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. It can be classified as marginal, partial, or total, depending on the degree of overlap. The mode of delivery for placenta previa depends on several factors, such as the type of previa, the amount of bleeding, the gestational age, and the fetal status. However, women with total placenta previa have no chance of delivering vaginally, as the placenta completely blocks the birth canal. Therefore, they must have a cesarean section to avoid hemorrhage and fetal compromise.
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