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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Related Questions
Correct Answer is D
Explanation
Correct Answer is C
Explanation
C) Eat a light snack before bedtime.
The nurse should include the instruction to eat a light snack before bedtime to promote nighttime sleep in an older adult. A light snack can help prevent hunger pangs during the night, making it easier to fall asleep and stay asleep.
The other options are not recommended for promoting nighttime sleep:
A) Performing exercises prior to bedtime can increase alertness and make it more difficult to fall asleep.
B) Taking a 1-hour nap during the day can disrupt the sleep-wake cycle and make it more challenging to sleep at night.
D) Staying in bed for at least 1 hour if unable to fall asleep is not recommended. If the client cannot fall asleep, it's better to get out of bed, engage in a quiet and relaxing activity, and return to bed when feeling sleepy to avoid frustration and anxiety associated with not being able to sleep.
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