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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 D

Explanation

A. Place the client in a side-lying position for the procedure: Paracentesis is typically performed with the client in an upright or high-Fowler’s position to allow fluid to pool in the lower abdomen for easier access and drainage.
B. Administer a low-volume hypertonic enema the night before the procedure: Enemas are not routinely indicated for paracentesis since the bowel does not obstruct access to ascitic fluid, making this an unnecessary step.
C. Ensure the client has a full bladder just prior to the procedure: A full bladder increases the risk of accidental puncture during needle insertion. The bladder should be emptied to reduce this risk.
D. Weigh the client before and after the procedure: Weighing the client allows the healthcare team to estimate the volume of ascitic fluid removed and assess fluid balance, making this a key nursing responsibility.

Correct Answer is C

Explanation

A. Bowel movement 5 days ago: Constipation is a common side effect of morphine and should be addressed, but it is not immediately life-threatening and can be managed with laxatives or stool softeners.
B. Pupil diameter 6 mm: Pupil dilation is not a typical concern with morphine; miosis (constriction) is more commonly expected. While abnormal pupil size can indicate neurologic or drug-related issues, hypotension takes priority here.
C. Blood pressure 80/40 mm Hg: Hypotension is a serious adverse effect of morphine that may indicate circulatory depression. It requires immediate intervention to prevent inadequate organ perfusion and potential shock.
D. Urinary output 120 mL/4 hr: This output equals 30 mL/hr, which is within the expected minimum range. No immediate intervention is required, though continued monitoring is appropriate.

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