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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Completely saturating a perineal pad within 15 minutes indicates excessive postpartum bleeding, which is most commonly caused by uterine atony (failure of the uterus to contract effectively after delivery). Massaging the fundus stimulates uterine muscles to contract, helping to compress blood vessels at the placental site and control bleeding. This is the priority intervention to prevent further blood loss and potential hemorrhage.
Choice B rationale
Assessing vital signs is important to evaluate the extent of blood loss and the woman's hemodynamic stability. However, the immediate priority is to address the cause of the excessive bleeding by promoting uterine contraction. Vital sign assessment should follow fundal massage.
Choice C rationale
Calling the primary health care provider is necessary to report the excessive bleeding and implement further management if fundal massage is not effective. However, the nurse's immediate action should be to address the likely cause of the bleeding through fundal massage.
Choice D rationale
Initiating an intravenous (IV) infusion of Ringer's lactate solution may be necessary to restore fluid volume if significant blood loss has occurred or continues. However, the immediate priority is to stop the bleeding by promoting uterine contraction through fundal massage. IV fluids are a subsequent intervention to support hemodynamic stability.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should anticipate a provider prescription for pyridoxine due to the client’s severe dehydration.
Rationale for correct answers
Pyridoxine (vitamin B6) is recommended for nausea and vomiting in pregnancy (NVP), commonly known as hyperemesis gravidarum (HG), especially in patients with persistent symptoms leading to dehydration. Severe dehydration is confirmed by elevated urine specific gravity (normal: 1.002–1.030), low sodium (normal: 135–145 mEq/L), and positive ketones, indicating excessive vomiting and malnutrition.
Rationale for incorrect Response 1 options
- Antibiotics: There is no evidence of infection; urinalysis and WBC count are within normal limits.
- Magnesium sulfate: Used for eclampsia or preterm labor prevention, not for HG.
- Oxytocin: Stimulates uterine contractions and is contraindicated during early pregnancy unless labor induction is required.
Rationale for incorrect Response 2 options
- Urinary tract infection: No leukocytes or nitrites in urine, and WBC count is normal (4,500–11,000/mm³).
- Preeclampsia: No proteinuria or hypertension (≥140/90 mm Hg).
- Preterm labor: No uterine contractions or cervical changes.
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