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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

Explanation

A. Stop the procedure: Stopping the blood transfusion immediately is the priority to prevent further exposure to the potentially harmful blood product causing the wheezing. This action helps minimize the risk of progression to a more severe transfusion reaction or anaphylaxis.
B. Administer an antihistamine: Antihistamines may relieve allergic symptoms but should only be given after the transfusion is stopped and the client is assessed. Administering medication without stopping the transfusion first could worsen the reaction.
C. Administer oxygen: Providing oxygen supports the client’s respiratory function during wheezing, which may indicate hypoxia. Oxygen administration is important but secondary to stopping the transfusion to eliminate the cause.
D. Initiate an infusion of 0.9% sodium chloride using new tubing: Starting a saline infusion with new tubing helps maintain IV access and prevent clotting after stopping the transfusion. This action is necessary but follows stopping the transfusion as the first priority.

Correct Answer is D

Explanation

A. Wart-like texture: A wart-like texture is more typical of squamous cell carcinoma or benign lesions like seborrheic keratosis. Melanomas usually do not have a rough, wart-like surface.
B. Firm and rubbery: Firm, rubbery nodules are more consistent with benign skin growths such as dermatofibromas. Melanomas tend to have irregular texture and color rather than a uniform firmness.
C. A central crater with rolled borders: This description fits basal cell carcinoma, which often presents with a pearly nodule and central ulceration. Melanomas do not commonly have this crater-like appearance.
D. Asymmetric with variegated ring: Melanomas are typically asymmetric with uneven, irregular borders and multiple colors. This variegation and asymmetry are classic warning signs distinguishing melanoma from other lesions.

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