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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Wash the penis from the scrotum to the tip using a spiral motion. B. Use water with no soap to prevent skin irritation. C. Don sterile gloves to prevent infection. D. Discard the washcloth after cleansing the urethral meatus.

Correct Answer is D

Explanation

The correct answer is choice d.

Choice A rationale:

Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.

Choice B rationale:

Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.

Choice C rationale:

While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.

Choice D rationale:

Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.

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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?