A nurse is preparing to administer an IV loading dose of magnesium sulfate to a client who has preeclampsia with severe features.
Which of the following actions should the nurse take?
Administer the medication over 30 min using an infusion pump
Place the client in a supine position with a wedge under the right hip
Monitor the client’s blood pressure every 15 min during the infusion
Have calcium gluconate available at the bedside as an antidote.
The Correct Answer is D
The correct answer is choice D. Have calcium gluconate available at the bedside as an antidote. Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia. However, it can also cause toxicity and respiratory depression if the serum level is too high. Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.
Choice A is wrong because the medication should be administered over 20-30 minutes using an infusion pump.
A shorter infusion time may increase the risk of adverse effects.
Choice B is wrong because the client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.
Choice C is wrong because the client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.
Blood pressure is an indicator of the severity of preeclampsia and the effectiveness of magnesium sulfate therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Methyldopa is a drug that lowers blood pressure by reducing the activity of the sympathetic nervous system.
One of the possible side effects of methyldopa is hypotension, which means abnormally low blood pressure.Hypotension can cause dizziness, fainting, and shock.
Choice A) Bradycardia is wrong because methyldopa does not affect the heart rate directly.Bradycardia means a slow heart rate, which can be caused by other drugs or conditions.
Choice C) Hyperkalemia is wrong because methyldopa does not affect the potassium levels in the blood.Hyperkalemia means high potassium levels, which can be caused by kidney problems or other drugs.
Choice D) Hyperglycemia is wrong because methyldopa does not affect the glucose levels in the blood.Hyperglycemia means high glucose levels, which can be caused by diabetes or other conditions.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for heart rate are 60 to 100 beats per minute, for potassium are 3.5 to 5.0 mmol/L, and for glucose are 70 to 100 mg/dL.
Correct Answer is B
Explanation
The correct answer is choice B. The client’s urine output is at least 30 mL/hr.This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.
A normal urine output is a sign that the kidneys are functioning well and that the fluid balance is maintained.
Choice A is wrong because the client’s blood pressure may not normalize even with magnesium sulfate therapy.
Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure.Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.
Choice C is wrong because the client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant.
A normal reflex response is 2+, but a lower response (1+ or 0) may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.
Choice D is wrong because the client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.
A normal respiratory rate is 12 to 20 breaths per minute, but a lower rate (less than 12) may indicate magnesium toxicity, which requires immediate treatment with calcium gluconate.
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