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.

Answer and Explanation

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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Correct Answer is B

Explanation

The correct answer is choice B: Dyspnea.

Choice B rationale: Dyspnea, or difficulty breathing, is a potential indication of a recurrent pulmonary embolism and should be reported immediately. Early detection and intervention are crucial to prevent life-threatening complications.

Choice A rationale: Hypotension may be a concerning finding in postoperative clients, but it is not the priority for a client with a history of pulmonary embolism. Hypotension could be related to various factors like bleeding or anesthesia effects.

Choice C rationale: Dry cough may occur as a result of irritation or inflammation in the airway due to the surgical procedure or anesthesia. Although it should be monitored, it is not the highest priority in this situation.

Choice D rationale: Tachycardia can be a common postoperative finding due to pain, anxiety, or other factors. Although it should be monitored and addressed, it is not the most critical concern in this case. Dyspnea is more closely related to a possible pulmonary embolism and should be reported promptly.

A. Uneven shoulder and pelvic heights. B. Exaggerated curvature of the sacrum. C. Limited range-of-motion of the hips. D. Mild pain in the hip region.

Correct Answer is A

Explanation

Choice A rationale:

"Uneven shoulder and pelvic heights." This is the correct answer. Uneven shoulder and pelvic heights, along with an asymmetrical appearance of the spine when viewed from the back, are clinical manifestations of scoliosis. Scoliosis is a sideways curvature of the spine that often develops during the growth spurt before puberty. Screening for scoliosis typically involves assessing the alignment of the spine and looking for these asymmetries.

Choice B rationale:

Exaggerated curvature of the sacrum is not a typical sign of scoliosis. Scoliosis primarily affects the upper back and can cause a side-to-side curvature of the spine, not the sacrum.

Choice C rationale:

Limited range-of-motion of the hips is not a specific indicator of scoliosis. Restricted hip movement might suggest other musculoskeletal issues but is not directly related to scoliosis.

Choice D rationale:

Mild pain in the hip region is not a characteristic symptom of scoliosis. While scoliosis can cause discomfort, it typically manifests as back pain, not specifically in the hip region. Pain symptoms can vary widely among individuals and might not be present in all cases of scoliosis.

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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?

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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?