A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 98.1F, pulse rate of 96 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 135/90 mm Hg, 1+ deep tendon reflexes, and not ankle clonus. The nurse calls the physician, anticipating an order for:
Select one:
Diazepam.
Hydralazine orally twice a day.
Calcium Gluconate
Second bolus of Magnesium sulfate.
The Correct Answer is C
a. Diazepam is not indicated for the treatment of severe preeclampsia.
b. Hydralazine orally twice a day is not indicated for the treatment of severe preeclampsia.
c. Calcium Gluconate is indicated for the treatment of hypermagnesemia, which can occur as a result of magnesium sulfate infusion.
d. This will worsen the magnesium toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. An abnormal odor of the amniotic fluid, such as a foul or fishy smell, may indicate infection and is a concern with ruptured membranes and an elevated temperature.
b. This may be necessary if the client has an infection or other complications, but it is not the first action to take.
c. This is not an appropriate action when the client has an elevated temperature and ruptured membranes.
d. Glucocorticoids may be administered to promote fetal lung maturity in preterm labor, but they are not appropriate in this situation.
Correct Answer is C
Explanation
a. The client should also be placed in Trendelenburg or knee-chest position to reduce cord compression.
b. This is not the first action to take when the umbilical cord is prolapsed.
c. This is a medical emergency that requires immediate intervention to prevent fetal hypoxia and death. The nurse should insert a gloved hand into the vagina and apply upward pressure on the presenting part to lift it off the cord until delivery.
d. This may be necessary if the cord compression cannot be relieved, but the first priority is to relieve the cord compression.
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