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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.
B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.
C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.
D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.
Correct Answer is D
Explanation
Rationale:
A. Acrocyanosis: This is a bluish discoloration of the hands and feet that is common in newborns during the first 24 to 48 hours after birth due to immature circulation. It is not a sign of sepsis.
B. Hypertension: Newborns with sepsis are more likely to present with hypotension due to systemic infection and poor perfusion. Hypertension is not typically associated with neonatal sepsis.
C. Rust-stained urine: This discoloration can occur in newborns from urate crystals in the first few days of life and is considered a normal finding, not an indicator of infection.
D. Retractions: Retractions indicate increased work of breathing and respiratory distress, which can occur in newborn sepsis due to systemic infection affecting respiratory function. This is a concerning finding that warrants prompt evaluation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.