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","D"]
Explanation
The correct answer is choice A, B, C and D.These choices reflect the laboratory findings that are expected in a client who has HELLP syndrome.HELLP syndrome is a rare pregnancy complication that is a type of preeclampsia and has similar symptoms.It can cause serious blood and liver problems.
Choice A is correct because hemoglobin of 9 g/dL indicates hemolysis, which is the breaking down of red blood cells.The normal range of hemoglobin for pregnant women is 11 to 16 g/dL.
Choice B is correct because platelets of 90,000/mm3 indicate thrombocytopenia, which is a low platelet count.The normal range of platelets for pregnant women is 150,000 to 400,000/mm3.
Choice C is correct because AST of 120 U/L indicates elevated liver enzymes, which reflect liver injury.The normal range of AST for pregnant women is 10 to 40 U/L.
Choice D is correct because LDH of 600 U/L indicates elevated lactate dehydrogenase, which is a marker of hemolysis.The normal range of LDH for pregnant women is 140 to 280 U/L.
Choice E is wrong because WBC of 15,000/mm3 indicates leukocytosis, which is not a feature of HELLP syndrome.The normal range of WBC for pregnant women is 5,000 to 15,000/mm3.
Correct Answer is B
Explanation
Methyldopa is a drug that lowers blood pressure by reducing the activity of the sympathetic nervous system.
One of the possible side effects of methyldopa is hypotension, which means abnormally low blood pressure.Hypotension can cause dizziness, fainting, and shock.
Choice A) Bradycardia is wrong because methyldopa does not affect the heart rate directly.Bradycardia means a slow heart rate, which can be caused by other drugs or conditions.
Choice C) Hyperkalemia is wrong because methyldopa does not affect the potassium levels in the blood.Hyperkalemia means high potassium levels, which can be caused by kidney problems or other drugs.
Choice D) Hyperglycemia is wrong because methyldopa does not affect the glucose levels in the blood.Hyperglycemia means high glucose levels, which can be caused by diabetes or other conditions.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for heart rate are 60 to 100 beats per minute, for potassium are 3.5 to 5.0 mmol/L, and for glucose are 70 to 100 mg/dL.
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