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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
No explanation
Correct Answer is D
Explanation
Explanation: MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in various parts of the body. The nurse should wear a gown when assisting the client with personal hygiene to prevent contact transmission of MRSA to other clients or staff members. The nurse should also wear gloves and a mask and perform hand hygiene before and after contact with the client or their environment. The nurse should remove personal protective equipment before leaving the client's room and dispose of it properly to avoid contamination of other areas or surfaces. Negative air pressure is not required for MRSA isolation because it is not an airborne infection. The client's visitors should not be restricted, but they should be educated on the proper use of personal protective equipment and hand hygiene when visiting the client.
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