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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Having the client pant during the next contractions helps to prevent premature pushing. Panting, or controlled breathing, reduces the urge to bear down, which can help prevent cervical swelling or tearing until full dilation is achieved.
Choice B rationale: Assisting the client into a comfortable position is important but not the immediate priority. The client should be instructed to use techniques to prevent pushing.
Choice C rationale: Helping the client to the bathroom to void is not appropriate at this stage of labor, as it may increase the risk of complications and is not the immediate priority.
Choice D rationale: Observing the perineum for signs of crowning is crucial. This action helps the nurse determine if the client is indeed ready to push and if the baby is descending properly. It ensures that the timing for pushing is optimal to prevent complications during delivery.
Correct Answer is B
Explanation
Choice A rationale
Intermittent abdominal pain following the passage of bloody mucus can be a sign of labor or other complications, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice B rationale
Painless red vaginal bleeding is a classic symptom of placenta previa. This occurs because the placenta is covering part or all of the cervix, leading to bleeding as the cervix begins to thin and open in preparation for labor.
Choice C rationale
Abdominal pain with scant red vaginal bleeding could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice D rationale
Increasing abdominal pain with a non-relaxed uterus could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
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