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 C
Explanation
Choice A) Newborns are abdominal breathers is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a characteristic of how newborns breathe. Abdominal breathing means that the diaphragm and the abdominal muscles are the main muscles used for breathing, rather than the chest muscles. Newborns are abdominal breathers because their chest wall is more compliant and less stable than adults, and their intercostal muscles are not fully developed. Abdominal breathing does not affect the accuracy or duration of measuring the respiratory rate, as long as the abdomen is visible and palpable. Therefore, this response is irrelevant and inaccurate.
Choice B) Activity will increase the respiratory rate is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a factor that can influence the respiratory rate. Activity means any physical or mental exertion that requires more oxygen and energy from the body. Activity can increase the respiratory rate, as well as the heart rate and blood pressure, to meet the increased oxygen demand and carbon dioxide removal. However, activity does not affect the accuracy or duration of measuring the respiratory rate, as long as the newborn is calm and resting during the measurement. Therefore, this response is irrelevant and inaccurate.
Choice C) The rate and rhythm of breath are irregular in newborns is correct because this is a reason why the respiratory rate should be counted for a complete minute. The rate and rhythm of breath refer to how fast and how regularly one breathes. Newborns have an irregular rate and rhythm of breath, which means that they breathe at different speeds and intervals, sometimes pausing for a few seconds between breaths. This is normal and harmless for newborns, as long as they do not stop breathing for more than 20 seconds or show signs of distress. However, it can make it difficult to measure the respiratory rate accurately, as counting for a shorter period may not reflect the true average rate. Therefore, counting for a complete minute can ensure a more reliable measurement. Therefore, this response is clear and accurate.
Choice D) Newborns do not expand their lungs fully with each respiration is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a feature of how newborns breathe.
Lung expansion means how much air one inhales and exhales with each breath. Newborns do not expand their lungs fully with each respiration, because they have smaller lung volumes and capacities than adults, and they breathe more shallowly and rapidly. However, lung expansion does not affect the accuracy or duration of measuring the respiratory rate, as long as the chest or abdomen movement is visible and palpable. Therefore, this response is irrelevant and inaccurate.
Correct Answer is C
Explanation
Choice a) Consult the physician, because the dose is too high is incorrect because this is not a necessary or appropriate action for a nurse who is following a valid order for betamethasone. Betamethasone is a corticosteroid that can be used to accelerate fetal lung maturation and reduce the risk of respiratory distress syndrome and other complications in preterm infants. The recommended dose for betamethasone is 12 mg IM every 24 hours for two doses, which is exactly what the physician ordered. Therefore, there is no reason to question or consult the physician about the dose, as it is within the normal range and based on evidence-based practice.
Choice b) Schedule the second dose for 11 am on the next day is incorrect because this is not a correct or accurate way to implement the order for betamethasone. Betamethasone should be given at least 24 hours apart, but not more than 48 hours apart, to achieve optimal fetal lung development and neonatal outcomes. Scheduling the second dose for 11 am on the next day would result in a 24-hour interval between the doses, which is acceptable, but not ideal. The best time to schedule the second dose would be between 24 and 48 hours after the first dose, such as at 11 pm on the same day or at 7 am on the next day.
Choice c) Prepare to administer the medication intramuscularly between contractions is correct because this is the best and most appropriate way to implement the order for betamethasone. Betamethasone should be given by intramuscular injection in a large muscle mass, such as the deltoid or gluteus, using a 21-gauge needle and a syringe with an air lock. The injection site should be cleaned with alcohol and aspirated before injecting. The medication should be administered between contractions, when the uterine blood flow is maximal and the fetal absorption is optimal. The nurse should also monitor the woman and the fetus for any adverse effects of betamethasone, such as maternal hyperglycemia, hypertension, infection, or edema, or fetal tachycardia, hypoglycemia, or infection.
Choice d) Explain to the woman that this medication will reduce her heart rate and help her to breathe easier is incorrect because this is not a true or relevant statement about betamethasone. Betamethasone does not have any direct effect on the maternal heart rate or respiratory function, as it is mainly intended to improve the fetal lung maturation and reduce the risk of respiratory distress syndrome and other complications in preterm infants.
Betamethasone may cause some side effects such as increased blood pressure, blood sugar, or fluid retention in the mother, which may affect her cardiovascular or respiratory status indirectly. However, these effects are usually transient and mild, and do not outweigh the benefits of betamethasone for the fetus. Therefore, this statement is misleading and inaccurate.
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