A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.
Which of the following actions should the nurse include in the plan?
Give the client protamine if signs of magnesium sulfate toxicity occur.
Monitor the FHR via Doppler every 30 min.
Restrict the client's total fluid intake to 250 mL/hr.
Measure the client's urine output every hour.
The Correct Answer is D
Choice A rationale:
Give the client protamine if signs of magnesium sulfate toxicity occur. Protamine is not the antidote for magnesium sulfate toxicity. Calcium gluconate or calcium chloride is used to counteract the effects of magnesium sulfate toxicity by antagonizing the action of magnesium on the neuromuscular junction and the heart.
Choice B rationale:
Monitor the FHR via Doppler every 30 min. While fetal heart rate (FHR) monitoring is important during magnesium sulfate infusion due to the risk of fetal distress, using Doppler every 30 minutes may not provide continuous and accurate monitoring. Continuous electronic fetal monitoring is the standard of care in this situation.
Choice C rationale:
Restrict the client's total fluid intake to 250 mL/hr. Magnesium sulfate is excreted by the kidneys, so maintaining adequate urine output is crucial to prevent magnesium toxicity. Restricting fluid intake to 250 mL/hr would likely reduce urine output, leading to an increased risk of magnesium sulfate accumulation in the body, which could be harmful.
Choice D rationale:
Measure the client's urine output every hour. Monitoring urine output is essential during magnesium sulfate infusion as it helps assess renal function and magnesium excretion. Adequate urine output (at least 30 mL/hr) is necessary to prevent magnesium toxicity. Therefore, measuring the client's urine output every hour is a critical nursing intervention to ensure the safety of the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
No explanation
Correct Answer is D
Explanation
Choice A rationale:
Borderline personality disorder is characterized by impulsivity, unstable relationships, and mood swings. While individuals with this disorder may have concerns about details, it is not the primary characteristic of the disorder. The impulsivity exhibited by these clients is a more prominent feature.
Choice B rationale:
While individuals with borderline personality disorder may struggle with interpersonal relationships and may sometimes display seductive behavior, this is not a defining characteristic of the disorder. The primary concern lies in their impulsivity and emotional instability.
Choice C rationale:
Clinginess can be a feature of borderline personality disorder, but it is not the defining characteristic. The disorder is more accurately characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, marked impulsivity that begins by early adulthood and is present in various contexts.
Choice D rationale:
Borderline personality disorder is indeed marked by impulsive behavior, one of the key diagnostic criteria according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This impulsivity often leads to self-damaging behaviors, such as reckless driving, substance abuse, and unsafe sex. Including this information in the in-service is crucial for an accurate understanding of the disorder.
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