A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?
Administer calcium gluconate
Discontinue the infusion.
Assess the fetal heart rate.
Obtain the client's magnesium level.
The Correct Answer is B
A. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity, but it should be given after stopping the infusion and assessing the client’s respiratory status. Immediate discontinuation takes priority.
B. Discontinue the infusion: Difficulty breathing indicates a potential magnesium sulfate toxicity or respiratory depression, which is a life-threatening emergency. The first action is to stop the infusion to prevent further accumulation.
C. Assess the fetal heart rate: Monitoring the fetus is important, but maternal safety takes priority over fetal assessment in a potential toxic reaction. Stabilizing the mother comes first.
D. Obtain the client's magnesium level: Lab assessment is useful for confirming toxicity, but it should not delay immediate intervention. Stopping the infusion takes precedence over obtaining levels.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Current fecal impaction: While fecal impaction requires treatment, it is not related to the safety or pharmacologic effects of conjugated estrogen therapy and does not constitute a contraindication.
B. Present report of abdominal pain: Abdominal pain requires evaluation, but it is nonspecific and not an absolute contraindication to conjugated estrogen unless related to certain underlying conditions like liver disease or cancer.
C. Thrombophlebitis: Estrogen increases the risk of thromboembolic events by promoting clot formation. A history or presence of thrombophlebitis makes estrogen therapy unsafe due to the elevated risk of worsening venous thromboembolism.
D. Diverticulitis: Diverticulitis is an inflammatory bowel condition that is not directly affected by estrogen therapy. It would not typically prohibit the use of conjugated estrogen unless complications or comorbidities present additional risks.
Correct Answer is C
Explanation
A. Bleeding gums: Mild bleeding gums can occur during pregnancy due to increased vascularity and hormonal changes. While uncomfortable, this finding is generally not urgent and can be managed with routine oral care.
B. Fundal height of 26 cm: A fundal height slightly above the gestational age (24 weeks vs. 26 cm) may be within normal variation, especially if the client has a larger fetus or multiple gestations. It should be monitored but is not immediately concerning.
C. Periorbital edema: Swelling around the eyes can be an early sign of preeclampsia, a potentially serious pregnancy complication. This finding should be reported promptly to the provider for further assessment and management.
D. White vaginal discharge: Mild, white, and non-odorous discharge (leukorrhea) is common during pregnancy due to hormonal changes. It is typically considered normal unless accompanied by odor, itching, or irritation.
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