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 B
Explanation
a. A woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago with normal fetal movements is not a priority assessment as long as there are no signs of fetal distress.
b. A woman who is 9 cm dilated and fully effaced and is requesting to go to the bathroom to have a bowel movement is in the second stage of labor, which means that the cervix is fully dilated and the fetus is descending in the birth canal. The urge to have a bowel movement is a sign that the fetal head is pressing on the rectum and that delivery is imminent. This patient needs immediate attention and preparation for delivery.
c. A woman at 27 weeks' gestation who noted scant vaginal bleeding today after having sexual intercourse in the morning may be experiencing placenta previa or placental abruption but this is not a priority compared to the woman in option b who is yet to deliver.
d. A woman who is 2 cm dilated and 80% effaced and is crying and shows mild anxiety is not a priority assessment as long as there are no signs of fetal distress.
Correct Answer is B
Explanation
a. A posterior presentation is when the fetus's back is toward the mother's back, and the fetal heart tones are usually heard on either side of the mother's abdomen.
b. A breech presentation is when the fetus's buttocks or feet are closest to the cervix. The fetal heart tones are usually heard above the umbilicus, at the midline, in a breech presentation.
c. A cephalic presentation is when the fetus's head is closest to the cervix, and the fetal heart tones are usually heard below the umbilicus, in either quadrant.
d. An oblique presentation is when the fetus's head or buttocks are angled toward one side of the pelvis, and the fetal heart tones are usually heard off-center, above or below the umbilicus.
e. A transverse presentation is when the fetus's spine is perpendicular to the mother's spine, and the fetal heart tones are usually heard on one side of the abdomen.
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