A nurse is planning care for a client who has preeclampsia with severe features and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse plan to include?
Administer terbutaline subcutaneously as needed for contractions.
Monitor the client's blood pressure every 2 hr.
Place suction equipment at the client's bedside.
Notify the provider of a urinary output of less than 50 mL/hr.
The Correct Answer is C
A. Administer terbutaline subcutaneously as needed for contractions: Terbutaline is a tocolytic used to suppress preterm labor, not to manage preeclampsia or magnesium sulfate therapy. Its use is unrelated to the care of a client receiving magnesium sulfate for seizure prophylaxis.
B. Monitor the client's blood pressure every 2 hr: In severe preeclampsia, blood pressure should be monitored more frequently than every 2 hours—typically every 15–30 minutes initially—because rapid changes can occur, and close monitoring is critical to prevent complications.
C. Place suction equipment at the client's bedside: Magnesium sulfate can cause respiratory depression as a serious adverse effect. Having suction equipment readily available ensures immediate intervention if the client experiences decreased respiratory effort or airway compromise, making this an essential safety measure.
D. Notify the provider of a urinary output of less than 50 mL/hr: While low urine output can indicate magnesium accumulation or renal impairment, the typical threshold for concern is less than 30 mL/hr. Although monitoring output is important, immediate bedside readiness for respiratory support is the priority intervention when administering magnesium sulfate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hallucinations: Hallucinations are common in clients experiencing delirium, especially when it is related to a febrile or acute medical illness. They can involve seeing or hearing things that are not present and reflect the acute cognitive disturbances characteristic of delirium.
B. Agnosia: Agnosia is the inability to recognize familiar objects, people, or sounds and is more commonly associated with neurodegenerative disorders such as dementia rather than acute delirium. It is not a typical finding in febrile-induced delirium.
C. Bradycardia: Delirium related to a febrile illness usually does not cause bradycardia. Vital signs are more likely to show tachycardia due to fever or systemic infection. Bradycardia would suggest a different cardiac or medication-related issue.
D. Aphasia: Aphasia, the impairment of language expression or comprehension, is generally linked to stroke or localized brain injury. It is not a common manifestation of acute delirium caused by a febrile illness.
Correct Answer is C
Explanation
A. First image: The rhythm shows irregular beats with visible P waves before each QRS complex, which is more consistent with normal sinus rhythm with occasional premature beats, not atrial fibrillation.
B. Second image: The rhythm appears regular with consistent P waves preceding each QRS, indicating normal sinus rhythm. There are no signs of atrial fibrillation.
C. Third image: The rhythm is irregularly irregular with no discernible P waves and variable R-R intervals, which are hallmark features of atrial fibrillation. This rhythm increases the client’s risk for thromboembolism and requires careful monitoring and management.
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