A nurse is caring for a client with gestational hypertension who has been prescribed magnesium sulfate to prevent seizures related to preeclampsia.
Which of the following assessments should the nurse prioritize?
Respiratory rate and depth
Urine output and color
Blood pressure and heart rate
Level of consciousness and reflexes
The Correct Answer is D
The correct answer is choice D) Level of consciousness and reflexes. This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes. These are signs that the dose of magnesium sulfate should be reduced or stopped.
The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.
Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.
Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures. However, urine output should be monitored to ensure adequate hydration and renal function.
Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy. Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.These are all risk factors for gestational hypertension according to various sources.
Some possible explanations for each choice are:
• Choice A: Maternal age over 35 years.Older women are more likely to have chronic hypertension, diabetes, or other conditions that increase the risk of gestational hypertension.
• Choice B: First pregnancy.Women who are pregnant for the first time are more likely to develop gestational hypertension than women who have had previous pregnancies.
• Choice C: Multiple gestation.Women who are carrying twins, triplets, or more are more likely to have gestational hypertension because of the increased placental mass and blood volume.
• Choice D: History of diabetes mellitus.This is not a risk factor for gestational hypertension, but it is a risk factor for preeclampsia, which is a more severe form of hypertension that involves proteinuria and organ damage.
Preeclampsia can develop from gestational hypertension or occur independently.
• Choice E: African American race.African American women are more likely to have gestational hypertension than women of other races or ethnicities.
This may be due to genetic, environmental, or social factors that affect blood pressure regulation.
Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg.Gestational hypertension is diagnosed when blood pressure is greater than or equal to 140/90 mmHg after 20 weeks of pregnancy and there is no proteinuria or other signs of preeclampsia.Gestational hypertension usually goes away after delivery, but it can increase the risk of complications for both the mother and the baby.
Correct Answer is D
Explanation
The correct answer is choice D. Have calcium gluconate available at the bedside as an antidote.Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia.However, it can also cause toxicity and respiratory depression if the serum level is too high.Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.
Choice A is wrong because the medication should be administered over 20-30 minutes using an infusion pump.
A shorter infusion time may increase the risk of adverse effects.
Choice B is wrong because the client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.
Choice C is wrong because the client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.
Blood pressure is an indicator of the severity of preeclampsia and the effectiveness of magnesium sulfate therapy.
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