A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.
Select all nursing interventions that apply in the care for the client.
Monitor deep tendon reflexes hourly.
Notify the physician if urinary output is less than 30 ml per hour.
Keep calcium gluconate on hand in case of a magnesium sulfate overdose.
Monitor maternal vital signs every 6 hours.
Monitor intake and output hourly.
Monitor renal function and cardiac function closely.
Correct Answer : A,B,C,E,F
Choice A rationale
Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.
Choice B rationale
A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.
Choice E rationale
Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.
Choice F rationale
Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Placenta previa is a condition where the placenta implants in the lower part of the uterus, potentially covering the cervix. It typically presents with painless vaginal bleeding, especially in the later trimesters, and is not directly associated with sudden, intense abdominal pain and cessation of contractions during labor.
Choice B rationale
Uterine rupture is a serious complication of vaginal birth after cesarean (VBAC), especially with strong, frequent contractions. The sudden onset of intense abdominal pain and the cessation of contractions, along with fetal distress indicated by the absent fetal heart rate tracing, are classic signs of uterine rupture. The prior cesarean scar weakens the uterine wall, making it susceptible to tearing under the stress of labor.
Choice C rationale
A prolapsed umbilical cord occurs when the cord descends into the vagina ahead of the presenting part, potentially compressing the fetal blood vessels and causing fetal distress. While fetal heart rate abnormalities would be present, it is not typically associated with sudden, intense maternal abdominal pain and cessation of contractions.
Choice D rationale
Abruptio placentae is the premature separation of the placenta from the uterine wall. It can cause sudden abdominal pain, vaginal bleeding (though not always), and fetal distress. However, the cessation of uterine contractions is not a typical finding in abruptio placentae. Contractions may continue, although they might be accompanied by increased uterine tone.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B,C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B,C"}}
Explanation
- Postpartum Endometritis is the most likely concern here, considering the fever, foul-smelling lochia, uterine tenderness, and tachycardia.
- Postpartum Hemorrhage is a possibility due to the boggy uterus and tachycardia, though her bleeding appears moderate.
- Lactational Mastitis is unlikely since the patient has no breast tenderness or redness.
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