The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?
Insert a Foley catheter with a urimeter to monitor hourly output
Have calcium gluconate immediately available
Provide a quiet environment with subdued lighting.
Assess deep tendon reflexes (DTRS) every 4 hours.
The Correct Answer is B
A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.
B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.
C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.
D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["450"]
Explanation
- To calculate the infusion rate, use the formula:
(mL of solution / grams of drug) x (grams ordered / minutes to infuse) x 60
- In this case, the formula becomes: (500 mL / 20 g) x (6 g / 20 min) x 60
- Simplify and solve: (25 mL / g) x (0.3 g / min) x 60
- The answer is 450 mL/hour
- The nurse should set the infusion pump at 450 mL/hour
Correct Answer is D
Explanation
A. Describe genetic testing protocols: While genetic testing may be part of prenatal care, it's not the primary concern for a pregnant woman addicted to heroin. The focus should be on managing the addiction and promoting a healthy pregnancy.
B. Discontinue the methadone right away: Abruptly stopping methadone, or any opioid replacement therapy, can lead to withdrawal symptoms, which can be harmful to both the mother and the fetus. It's crucial for pregnant individuals on methadone to work closely with their healthcare provider to manage the transition.
C. Sign up for group therapy sessions: Group therapy can be a supportive intervention for individuals dealing with addiction, but it should be part of a comprehensive treatment plan that includes medical management.
D. Start a prenatal care plan as soon as possible: This is the most appropriate choice. Prenatal care is crucial for monitoring the health of both the mother and the baby. Starting early allows healthcare providers to address any potential issues and provide necessary support. This includes managing the mother's opioid addiction through medications like methadone, which can be administered under close medical supervision during pregnancy.
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