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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 B

Explanation

A. Remind the client to eat scheduled meals daily: At the end of life, appetite often decreases, and forcing scheduled meals can cause discomfort. Encouraging small, preferred foods as tolerated is more appropriate.
B. Offer the client a blanket to keep warm: Clients nearing end of life often experience cold intolerance due to decreased circulation and metabolism. Providing warmth helps maintain comfort and dignity.
C. Speak in a loud tone when addressing the client: Speaking loudly can be perceived as disrespectful or frightening, especially if the client is confused or hearing impaired. A calm, gentle tone is more supportive.
D. Place the client in a supine position: The supine position may increase discomfort or breathing difficulties in some terminal clients; positioning should focus on comfort and ease of breathing, often semi-Fowler’s or side-lying

Correct Answer is A

Explanation

A. “Morphine 3 mg subcutaneous every 4 hr PRN for pain.": This entry uses correct and safe medication documentation practices. It includes the drug name, dose without trailing zero, full route written out, frequency, and indication, reducing the risk of misinterpretation.
B. “Morphine 3 mg SC q 4 hr PRN for pain,": Abbreviations like “SC” and “q” are discouraged by The Joint Commission due to the potential for misreading. The full words "subcutaneous" and "every" are preferred for clarity and safety.
C. “Morphine 3.0 mg sub q every 4 hr PRN for pain.": The trailing zero (“3.0 mg”) increases the risk of dosage error if the decimal point is not seen. Safe practice omits trailing zeros in medication doses.
D. “Morphine 3 mg SQ every 4 hr PRN for pain.": The abbreviation “SQ” can be mistaken for “SL” (sublingual) or “5Q,” leading to errors. The route should be written out fully as “subcutaneous” to ensure clear communication.

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