A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent.
What action should the nurse take?

Prepare for an emergency cesarean birth

Position the client in Trendelenburg

Discontinue the medication infusion

Assess maternal blood glucose

Answer and Explanation

The Correct Answer is C

Choice A rationale

Preparing for an emergency cesarean birth may be necessary in some cases of preeclampsia, particularly if there are signs of fetal distress or if the condition is not responding to treatment. However, in this scenario, the client’s symptoms are indicative of magnesium toxicity, not worsening preeclampsia.

Choice B rationale

Positioning the client in Trendelenburg (with the head lower than the feet) is not typically used in the management of preeclampsia or magnesium toxicity.

Choice C rationale

Discontinuing the medication infusion is the correct action in this scenario. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) are indicative of magnesium toxicity, a potential complication of magnesium sulfate therapy. Magnesium sulfate is used in the management of preeclampsia to prevent seizures, but it can cause toxicity if the levels become too high. If signs of toxicity occur, the infusion should be discontinued immediately.

Choice D rationale

Assessing maternal blood glucose may be necessary in some cases, particularly if the client has a history of diabetes. However, it is not the priority in this scenario, as the client’s symptoms are indicative of magnesium toxicity, not hyperglycemia.

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Correct Answer is C

Explanation

Choice A rationale

Betamethasone does not increase the fetal heart rate. It is a corticosteroid given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.

Choice B rationale

Betamethasone is not used to stop preterm labor contractions. Other medications, such as tocolytics, are used for this purpose.

Choice C rationale

This is the correct answer. Betamethasone is given to promote fetal lung maturity. It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.

Choice D rationale

Betamethasone does not halt cervical dilation. It is given to enhance fetal lung maturity, not to stop labor.

A. Unilateral, cramp-like abdominal pain. B. Severe nausea and vomiting. C. Uterine enlargement greater than expected for gestational age. D. Large amount of vaginal bleeding.

Correct Answer is A

Explanation

Choice A rationale

An ectopic pregnancy, where the fertilized egg attaches outside the uterus, often presents with unilateral, cramp-like abdominal pain. This is because as the fertilized egg grows in an area where it cannot survive, it can cause irritation and bleeding, leading to pain. This pain is often one-sided or unilateral and can vary from mild to severe. It’s one of the key symptoms that can suggest an ectopic pregnancy in the early weeks of gestation.

Choice B rationale

Severe nausea and vomiting are not typically the primary symptoms associated with an ectopic pregnancy. While nausea can be a symptom of early pregnancy, severe nausea and vomiting alone without other symptoms would not necessarily indicate an ectopic pregnancy.

Choice C rationale

Uterine enlargement greater than expected for gestational age is not a symptom of an ectopic pregnancy. In fact, because the pregnancy is not in the uterus, the size of the uterus may not correlate with the expected size at the given gestational age.

Choice D rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is not typically a large amount. The bleeding is often lighter than normal menstrual bleeding and may be associated with a change in color of the vaginal discharge.

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A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent. What action should the nurse take?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. Which of the following explanations should the nurse provide?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who is suspected to have an ectopic pregnancy at 8 weeks of gestation. What symptoms should the nurse expect to observe that are consistent with this diagnosis?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent.
What action should the nurse take?