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 A

Explanation

Choice A rationale:

Lavender oil is commonly used in aromatherapy and is known for its calming effects. However, it can trigger respiratory issues in individuals with asthma. Asthma is a chronic condition characterized by airway inflammation and bronchoconstriction, which can be exacerbated by inhaling certain substances, including strong odors and essential oils. Lavender oil, when inhaled, can potentially irritate the airways and worsen asthma symptoms. Therefore, a history of asthma is a contraindication for using lavender oil.

Choice B rationale:

Furosemide is a diuretic commonly used to treat fluid retention (edema) and hypertension. It works by increasing urine production and removing excess fluid from the body. Furosemide does not interact with lavender oil directly, and there is no known contraindication between these two substances.

Choice C rationale:

Alcohol use disorder is a condition characterized by an inability to control or stop alcohol consumption despite negative consequences. While alcohol abuse can have various health implications, it does not specifically interact with lavender oil in a way that constitutes a contraindication.

Choice D rationale:

Vitamin C is a water-soluble vitamin that plays a crucial role in various bodily functions, including immune system support and collagen synthesis. There is no evidence to suggest that taking vitamin C daily contraindicates the use of lavender oil. These two substances do not interact in a way that poses a risk to the individual.

A. Check the expiration date on the safety inspection sticker of the pump. B. Verify that the extension cord for the pump is ungrounded. C. Report the pump has a frayed cord and proceed with the infusion. D. Obtain a surge protector that can accommodate the pump and several other appliances.

Correct Answer is A

Explanation

Choice A rationale:

(Correct Choice) Checking the expiration date on the safety inspection sticker of the pump is essential to ensure the equipment is functioning properly and safely. Using expired equipment can compromise the client's safety and the effectiveness of the treatment.

Choice B rationale:

Verifying that the extension cord for the pump is ungrounded is important for electrical safety. However, it is not the nurse's responsibility to do this. This action should be performed by a qualified electrician or facility maintenance personnel.

Choice C rationale:

Reporting the pump with a frayed cord is essential. However, it is not safe to proceed with the infusion in this situation. Using damaged equipment can lead to electrical hazards and compromise the client's safety.

Choice D rationale:

Obtaining a surge protector is important for protecting the pump and other electrical appliances from power surges. While this is a good practice, it is not the first action the nurse should take when preparing to initiate intravenous fluids.

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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?