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
A platelet count of 50,000/mm³ is critically low (normal range is 150,000-450,000/mm³) in a client with pre-eclampsia. Thrombocytopenia is a serious complication of pre-eclampsia and can significantly increase the risk of bleeding and hemorrhage. This finding requires immediate reporting and intervention.
Choice B rationale
A hemoglobin level of 11 grams/dL is within the lower end of the normal range for postpartum women (typically 12-15 g/dL) and is not an immediate concern in the context of pre-eclampsia, unless there is a rapid decline or other concerning symptoms.
Choice C rationale
A creatinine level of 0.3 mg/dL is below the normal range for non-pregnant adults (typically 0.6-1.2 mg/dL) and might be lower in pregnancy due to increased glomerular filtration rate. While kidney function should be monitored in pre-eclampsia, this specific value is not immediately alarming.
Choice D rationale
A fasting blood glucose of 65 mg/dL is within the normal range (typically 70-100 mg/dL) and is not a typical finding that requires immediate reporting in pre-eclampsia, although gestational diabetes can sometimes coexist.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The condition that poses the greatest risk to the newborn is meconium aspiration syndrome due to amniotic fluid.
Rationale for correct answers
Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid, leading to airway obstruction, chemical pneumonitis, and surfactant dysfunction. The presence of dark brown-greenish amniotic fluid, along with mild respiratory distress (nasal flaring, increased respiratory rate of 60/min), raises concern for MAS. Close monitoring for worsening respiratory symptoms is essential.
Amniotic fluid contamination with meconium increases the risk of lung inflammation and infection. The newborn’s vigorous condition suggests mild aspiration, but continuous observation is needed.
Rationale for incorrect Response 1 options
- Jaundice: While term newborns may develop physiological jaundice, there are no indications of hyperbilirubinemia or hemolysis in this case.
- Hypoglycemia: No jitteriness or poor feeding, and birth weight is within normal range; hypoglycemia more commonly affects preterm or low birth weight infants.
- Cold stress: The newborn is under a radiant warmer, and temperature is within normal range (36.5°C).
Rationale for incorrect Response 2 options
- Birth weight: No signs of growth restriction or macrosomia-associated complications.
- Acrocyanosis: Normal in newborns due to immature circulation, not an indicator of respiratory compromise.
- Apgar scores: Strong Apgar scores (8 and 9) suggest good adaptation to extrauterine life.
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