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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Cerebral hemorrhage.Eclampsia is a severe complication of preeclampsia that causes seizures and can lead to stroke or death.Cerebral hemorrhage is bleeding in the brain that can result from high blood pressure and swelling in the brain caused by eclampsia.It is one of the most common causes of death in women with eclampsia.
Choice B. Pulmonary edema is wrong because it is not the most common cause of death in women with eclampsia.
Pulmonary edema is fluid accumulation in the lungs that can impair breathing and oxygen exchange.It can occur as a complication of eclampsia, but it is less frequent than cerebral hemorrhage.
Choice C. Liver rupture is wrong because it is not the most common cause of death in women with eclampsia.
Liver rupture is a rare but serious complication of eclampsia that involves bleeding from the liver due to increased pressure and damage to the liver tissue.It can cause severe abdominal pain, shock and death.
Choice D. Disseminated intravascular coagulation (DIC) is wrong because it is not the most common cause of death in women with eclampsia.
DIC is a condition where the blood clotting system becomes overactive and forms clots throughout the body, leading to bleeding and organ failure.It can occur as a complication of eclampsia, but it is less common than cerebral hemorrhage.
Normal ranges for blood pressure are below 140/90 mmHg and for proteinuria are below 300 mg/24 hours or below 30 mg/dL in a urine sample.
Correct Answer is B
Explanation
The correct answer is choice B. The client’s urine output is at least 30 mL/hr.This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.
A normal urine output is a sign that the kidneys are functioning well and that the fluid balance is maintained.
Choice A is wrong because the client’s blood pressure may not normalize even with magnesium sulfate therapy.
Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure.Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.
Choice C is wrong because the client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant.
A normal reflex response is 2+, but a lower response (1+ or 0) may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.
Choice D is wrong because the client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.
A normal respiratory rate is 12 to 20 breaths per minute, but a lower rate (less than 12) may indicate magnesium toxicity, which requires immediate treatment with calcium gluconate.
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