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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Correct Answer is D
Explanation
Choice A rationale
Perinatal asphyxia refers to a lack of oxygen flow to the fetus around the time of birth. This can lead to multiple organ dysfunction and neurological issues, but it is not a common cause of a newborn being small for gestational age.
Choice B rationale
Preterm delivery can result in a newborn being small for their gestational age simply because they have not had the full amount of time to grow in the womb. However, preterm babies are typically compared to other preterm babies when assessing size, not to full-term babies.
Choice C rationale
Fetal hyperinsulinemia, or an excess of insulin in the fetus, can lead to excessive growth and a larger-than-average baby size (macrosomia), not a smaller size.
Choice D rationale
Placental insufficiency, where the placenta does not work as well as it should, can limit the amount of oxygen and nutrients the fetus receives. This can restrict the baby’s growth, leading to a small size for gestational age.
Correct Answer is A
Explanation
Choice A rationale
The recommended time for rubella immunization for a woman who does not have immunity is shortly after giving birth. The MMR vaccine, which protects against measles, mumps, and rubella, is a live virus vaccine and is not recommended during pregnancy.
Choice B rationale
While it’s important for a woman to have immunity to rubella before her next pregnancy, waiting until her next attempt to get pregnant to get the vaccine could potentially leave her unprotected if she becomes pregnant sooner than planned.
Choice C rationale
The MMR vaccine is not recommended during pregnancy, including in the third trimester.
Choice D rationale
The MMR vaccine is not recommended during pregnancy, including in the second trimester.
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