The patient has been on IV magnesium sulfate for severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature of 37.3 C, HR 88, RR 9. B/P 140/90, absent deep tendon reflexes, and no ankle clonus. The patient complains, "I am so thirsty and warm," and seems lethargic. The nurse's first action is to:
Call for a STAT magnesium level
Do nothing, this is the expected action of magnesium
Prepare to administer hydralazine
Decrease or Discontinue the magnesium sulfate infusion
The Correct Answer is D
A. Call for a STAT magnesium level. While obtaining a magnesium level is important to confirm magnesium toxicity, the priority action is to stop or reduce the infusion immediately to prevent further toxicity and respiratory depression.
B. Do nothing, this is the expected action of magnesium. Absent deep tendon reflexes, lethargy, and respiratory depression (RR 9) are signs of magnesium toxicity, not expected therapeutic effects. Immediate intervention is necessary to prevent worsening respiratory and cardiac complications.
C. Prepare to administer hydralazine. Hydralazine is used to treat hypertension in preeclampsia, but this patient’s blood pressure is not critically high, and the primary concern is magnesium toxicity, not hypertension. Administering hydralazine would not address the immediate life-threatening issue.
D. Decrease or Discontinue the magnesium sulfate infusion. The first action in magnesium toxicity is to stop or reduce the infusion to prevent further accumulation. If symptoms worsen, calcium gluconate, the antidote for magnesium toxicity, may be administered to reverse its effects, especially if respiratory depression progresses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Oligohydramnios. Oligohydramnios, or low amniotic fluid levels, is not a primary complication of pregestational diabetes. It is more commonly associated with conditions such as fetal growth restriction, post-term pregnancy, and rupture of membranes rather than maternal hyperglycemia.
B. Congenital fetal anomalies. Poor glycemic control during preconception and early pregnancy increases the risk of congenital anomalies, particularly affecting the heart, spine, and central nervous system. Hyperglycemia during organogenesis (first 8 weeks of gestation) can lead to defects such as neural tube defects and cardiac malformations.
C. Intrauterine fetal seizures. Fetal seizures in utero are extremely rare and are not a common complication of maternal diabetes. While neonatal hypoglycemia after birth can lead to seizures, maternal hyperglycemia does not directly cause seizures in the fetus.
D. Polyhydramnios. While polyhydramnios (excess amniotic fluid) can occur in pregnancies complicated by diabetes due to fetal polyuria, it is more associated with later pregnancy. The question specifically asks about preconception and early pregnancy risks, making congenital anomalies the best answer.
Correct Answer is A
Explanation
Professor Proctor emphasizes safety as the highest priority while traveling, including when coming to class. Ensuring that students arrive safely is considered more important than strict punctuality.
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