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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 {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Rationale for Essential Actions:

  • Monitor for elevated temperature: Epidural anesthesia can increase the risk of maternal fever due to decreased peripheral heat loss. Monitoring temperature helps detect infection or epidural-related hyperthermia early.
  • Assess for urinary retention:Epidural anesthesia can impair bladder sensation and motor control, making urinary retention common. Ongoing bladder assessments are crucial to prevent bladder distention and associated labor complications.
  • Encourage the client to turn from side to side: Repositioning promotes fetal descent and optimal uteroplacental perfusion, and helps prevent supine hypotension by avoiding vena cava compression in laboring women.

Rationale for Contraindicated Actions:

  • Assist the client with ambulation: Epidural anesthesia impairs lower extremity motor function and balance, posing a high fall risk. Bedrest is required after epidural placement unless sensation and motor function are fully restored and evaluated.
  • Inform the client to expect drowsiness: Drowsiness is not a typical or expected effect of epidural anesthesia. Sedation may indicate systemic effects or complications and should not be presented as expected.

Correct Answer is C

Explanation

A. Document assessment findings and interventions after providing care for a group of clients: Delaying documentation increases the risk of forgetting important details and can compromise accuracy and continuity of care. Timely documentation is critical.
B. Delay cleaning personal work area until the end of the shift: Postponing cleaning may lead to disorganization and inefficiency throughout the shift, potentially impacting infection control and readiness for patient care.
C. Complete activities for one client before moving to the next client: Focusing on completing care for one client at a time promotes continuity, reduces task repetition, and improves prioritization and time management.
D. Gather supplies for a client's dressing change after removing the old dressing: This approach wastes time and may expose the wound to contaminants. Preparing all supplies in advance supports efficiency and infection control.

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