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
Explanation
The correct answer is choice A) Serum magnesium level.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.It is often given intravenously and can also be used to prolong pregnancy for up to two days.However, magnesium sulfate can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Therefore, the nurse should monitor the serum magnesium level to ensure that it is within the therapeutic range of 4 to 7 mg/dL.
Choice B) Serum potassium level is wrong because magnesium sulfate does not affect the potassium level significantly.
Potassium is an electrolyte that regulates the nerve and muscle function, especially the heart.
The normal range of potassium level is 3.5 to 5.0 mEq/L.
Choice C) Serum sodium level is wrong because magnesium sulfate does not affect the sodium level significantly.
Sodium is another electrolyte that helps maintain fluid balance and blood pressure.
The normal range of sodium level is 135 to 145 mEq/L.
Choice D) Serum calcium level is wrong because magnesium sulfate does not affect the calcium level significantly.
Calcium is a mineral that is important for bone health, blood clotting, and muscle contraction.
The normal range of calcium level is 8.5 to 10.2 mg/dL.
Correct Answer is ["A","B","D","E"]
Explanation
The correct answer ischoice A, B, D and E.These are all signs and symptoms that may indicate worsening condition or preeclampsia in a client with gestational hypertension.Preeclampsia is a complication of pregnancy that is marked by high blood pressure and presence of proteins in urine.
Choice C is wrong because chest pain or shortness of breath are not typical symptoms of preeclampsia, but they may indicate other serious conditions such as heart problems or pulmonary edema.
If a client with gestational hypertension experiences these symptoms, they should seek immediate medical attention.
Normal ranges for blood pressure and proteinuria are:
• Blood pressure: less than 140/90 mm Hg.
• Proteinuria: less than 300 mg in a 24-hour urine collection or less than 30 mg/dL in a random urine sample.
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