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The nurse continues to care for the client who is at 30 weeks of

Exhibits

Complete the following sentence by using the lists of options.

Based on the client findings, the nurse should first

and then prepare to administer.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for Correct Options:

  • Apply oxygen via nasal cannula: The client is experiencing shallow respirations, SPO2 92%, lethargy, low urine output, and decreased DTRs, which are classic signs of magnesium sulfate toxicity. Administering oxygen helps improve oxygenation and mitigate hypoxia while preparing for further intervention.
  • Calcium gluconate: This is the antidote for magnesium sulfate toxicity. Given the client’s clinical signs such as depressed DTRs, lethargy, and shallow breathing, immediate preparation and administration of calcium gluconate is essential to reverse potentially life-threatening effects.

Rationale for Incorrect Options:

  • Reduce fluid intake: Although urine output is decreased, the primary concern is not fluid overload but rather signs of magnesium toxicity. Fluid restriction would not address the current emergent symptoms.
  • Discontinue IV infusion: Magnesium sulfate infusion should be discontinued if toxicity is suspected, but it's not the first action compared to applying oxygen. The infusion should be stopped as soon as respiratory support is provided.
  • Hydralazine: While this antihypertensive can treat severe hypertension in pregnancy, it is not the immediate priority in the setting of magnesium toxicity. Stabilizing respiratory and neurologic status takes precedence.
  • Nifedipine: This antihypertensive has already been prescribed and possibly administered earlier. Re-administering it would not be the correct response to signs of magnesium toxicity, and could exacerbate hypotension or bradycardia.


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Related Questions

Correct Answer is C

Explanation

A. Deflate the cuff quickly: Rapid deflation can result in missing the systolic and diastolic readings entirely, making the measurement inaccurate.
B. Place the arm above the level of the client’s heart: Elevating the arm above heart level can lead to falsely low blood pressure readings due to decreased perfusion.
C. Use the palpatory method to determine blood pressure: When auscultation is difficult, the palpatory method helps estimate the systolic pressure by palpating the radial pulse, guiding appropriate inflation for subsequent attempts.
D. Apply the largest cuff available: Using an improperly sized cuff, especially one that is too large, can yield inaccurate readings; the cuff size should be appropriate to the client’s arm circumference.

Correct Answer is B

Explanation

A. Carbamazepine: This medication is primarily used for long-term seizure control but is not effective in stopping an active status epilepticus episode due to its slower onset of action.
B. Lorazepam: Lorazepam is a benzodiazepine with rapid onset that is the first-line treatment to quickly stop seizures during status epilepticus, providing immediate central nervous system depression to control convulsions.
C. Clonazepam: Although clonazepam is a benzodiazepine used for seizure management, it is less commonly used in acute status epilepticus due to slower onset and availability of more effective alternatives like lorazepam.
D. Lamotrigine: Lamotrigine is an anticonvulsant used for maintenance therapy in seizure disorders, but it does not act quickly enough to manage status epilepticus emergencies.

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