Sem 4 - Unit 3 - Reproduction NCO
What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. 1 Restricting visitors 2 Limiting fluid intake 3 Preparing for a precipitate birth 4 Maintaining a quiet environment 5 Keeping magnesium gluconate at the bedside
1 Restricting visitors 4 Maintaining a quiet environment Visitors should be limited to significant others to reduce excessive stimuli that could precipitate a seizure. A quiet room helps reduce stimuli and therefore the risk of seizures. Fluid intake should not be restricted. A precipitous birth is not a usual side effect of magnesium sulfate therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be readily available if signs of toxicity appear.
Intravenous magnesium sulfate therapy is instituted for a client with severe preeclampsia who has a blood pressure of 170/110 mm Hg, a pulse of 108 beats/min, and a respiratory rate of 24 breaths/min. Eight hours later her blood pressure is 150/110 mm Hg, the pulse is 98 beats/min, the respiratory rate is 10 breaths/min, and the knee-jerk reflex is absent. What should the nurse do next? 1 Stop the infusion of magnesium sulfate and notify the primary healthcare provider. 2 Administer calcium gluconate, because it is an antidote to magnesium sulfate. 3 Continue the magnesium sulfate infusion, because the blood pressure is still high. 4 Check vital signs and reflexes in 1 hour and then discontinue the infusion if necessary.
1 Stop the infusion of magnesium sulfate and notify the primary healthcare provider. Near-toxic levels of magnesium sulfate are suggested by the disappearance of the knee-jerk reflex and by depressed respirations (fewer than 12 breaths/min). This is a life-threatening situation, and the primary healthcare provider must be notified immediately. Calcium gluconate may be given as an antidote, but the infusion of magnesium sulfate must be stopped first. Magnesium sulfate is not an antihypertensive. Waiting may put the client in danger of respiratory arrest; signs of toxicity require immediate intervention.
Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? 1 Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. 2 Intra-abdominal pressure on the iliac veins is maximized, and there is increased blood flow to the pelvic area. 3 Aortic compression is maximized, thereby decreasing uterine arterial pressure and increasing uterine blood flow. 4 Hemoconcentration is maximized, thereby reducing blood volume and cardiac output and increasing placental perfusion.
1 Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. In the left-lateral position the gravid uterus no longer compresses major vessels; cardiac output is maintained; glomerular filtration and uterine perfusion rates increase. Maximizing intra-abdominal pressure on the iliac veins will decrease, not increase, blood flow to the pelvic area. Maximizing aortic compression will decrease, not increase, uterine blood flow. Hemoconcentration occurs and uterine perfusion decreases in the standing and sitting positions.
A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate. What adverse effects indicate that the serum magnesium level may be excessive? Select all that apply. 1 Absence of the knee-jerk reflex 2 Urine output of 100 mL/hr 3 Blood pressure of 140/90 mm Hg 4 Apical pulse of 80 beats/min 5 Respiratory rate of 11 breaths/min
1 Absence of the knee-jerk reflex 5 Respiratory rate of 11 breaths/min An absence of the knee-jerk reflex is a manifestation of hyporeflexia; it is a possible indication of magnesium sulfate toxicity. A respiratory rate of 11 breaths/min is cause for concern; any rate slower than 12 breaths/min is a sign of magnesium sulfate toxicity. A urinary output of 100 mL/hr is adequate; output of less than 30 mL/hr indicates inadequate excretion of magnesium sulfate and the potential for toxicity. The maternal blood pressure is not directly related to magnesium sulfate administration or toxicity; however, decreased blood pressure indicates that the treatment has been effective. A pulse rate of 80 beats/min is an expected pulse rate, not an indicator of toxicity.
A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. 1 Headache 2 Constipation 3 Abdominal pain 4 Vaginal bleeding 5 Flulike symptoms
1 Headache 3 Abdominal pain 5 Flulike symptoms Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia.
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. 1 Monitoring deep tendon reflexes 2 Assessing urine output every 8 hours 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min
1 Monitoring deep tendon reflexes 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/hr must be reported to the primary healthcare provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary healthcare provider.
A client who is at risk for seizures as a result of severe preeclampsia is receiving an intravenous infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. 1 Proteinuria 2 Epigastric pain 3 Respirations of 10 breaths/min 4 Loss of patellar reflexes 5 Urine output of 40 mL/hr
3 Respirations of 10 breaths/min 4 Loss of patellar reflexes A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished reflexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia. Magnesium sulfate toxicity is not accompanied by proteinuria; proteinuria is a sign of preeclampsia. Epigastric pain is associated with severe eclampsia, not magnesium sulfate toxicity. Urine output of 40 mL/hr is an acceptable output; an output of less than 30 mL/hr may contribute to the development of a toxic level of magnesium.
The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site
4 Bleeding at the venipuncture site Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.
A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? 1 Gravida III with twins 2 Gravida V with endometriosis 3 Gravida II who had a 9-lb baby 4 Gravida I who has had an intrauterine fetal death
4 Gravida I who has had an intrauterine fetal death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.
A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What objective clinical finding indicates an impending seizure? 1 Persistent headache with blurred vision 2 Epigastric pain with nausea and vomiting 3 Spots and flashes of light before the eyes 4 Rolling of the eyes to one side with a fixed stare
4 Rolling of the eyes to one side with a fixed stare Rolling of the eyes to one side with a fixed stare is a sign of central nervous system involvement that the nurse can see without obtaining subjective data from the client. It is a sign of an impending seizure. Persistent headache with blurred vision, epigastric pain with nausea and vomiting, and spots and flashes of light before the eyes are all clinical manifestations of severe preeclampsia, not eclampsia.
What is the priority nursing action when caring for a client with disseminated intravascular coagulation? 1 Monitor for Homans sign. 2 Avoid giving intramuscular injections. 3 Take temperatures via the rectal route. 4 Apply sequential compression stockings.
2 Avoid giving intramuscular injections. Massive amounts of clots formed in the microcirculation deplete platelets and clotting factors, leading to bleeding; the trauma of an injection may cause excessive bleeding. Monitoring for Homans sign is associated with thrombophlebitis. Taking temperatures via the rectal route could be traumatic and precipitate bleeding. Sequential compression stockings are used to prevent thrombophlebitis.
A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. 1 Headache 2 Constipation 3 Abdominal pain 4 Vaginal bleeding 5 Visual disturbances
1 Headache 3 Abdominal pain 5 Visual disturbances Headache in severe preeclampsia is related to cerebral edema. Abdominal pain in severe preeclampsia is related to decreased circulating blood volume and generalized edema. Visual disturbances in severe preeclampsia are related to retinal edema. Constipation and vaginal bleeding are not related to preeclampsia.
An intravenous infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dosage is twice the usual adult dosage. When a nurse questions the dosage, the primary healthcare provider insists that it is the desired dosage and directs the nurse to administer the medication. How should the nurse respond to this directive? 1 Administer the dose and monitor the client. 2 Withhold the dose and notify the nurse manager. 3 Administer the dose and document it on the client's record. 4 Withhold the dose and notify the director of the obstetric department.
2 Withhold the dose and notify the nurse manager. To administer the incorrect dose would be an act of negligence that could endanger the client, and the nurse would be liable. If the dosage is not changed after the primary healthcare provider is questioned, the nurse should contact the nurse manager. The medication should be withheld, because it could cause respiratory depression and endanger both the client and fetus. The nurse should follow hospital protocol and notify the nurse manager, not the director of the obstetrics department, first.
A client with preeclampsia has a prescription for a magnesium sulfate infusion to be initiated. The nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply. 1 Patellar reflex 2 Output of urine 3 Respiratory rate 4 Body temperature 5 Urine specific gravity
1 Patellar reflex 2 Output of urine 3 Respiratory rate A baseline measurement of the patellar reflex should be obtained, because magnesium sulfate is a central nervous system depressant; an absence of patellar reflexes indicates magnesium sulfate toxicity. Magnesium sulfate is excreted by way of the kidneys; adequate urine output is necessary to prevent toxicity. Magnesium sulfate is a central nervous system depressant; a slowed respiratory rate is a sign of magnesium sulfate toxicity. Magnesium sulfate does not affect body temperature. The urine specific gravity test is not used before, during, or after magnesium sulfate therapy.
A nurse is teaching a client with preeclampsia regarding methods for improving her health. What is the most therapeutic instruction for the nurse to provide this client? 1 "Eat a sodium-restricted diet." 2 "Walk at least 1 mile (2.2 km) every day." 3 "Rest often in the side-lying position." 4 "Limit fluid intake to 1000 mL daily."
3 "Rest often in the side-lying position." Rest is advised to reduce arteriolar spasm, and the side-lying position promotes more efficient venous return to the heart; this improves cardiac output and placental perfusion. Sodium is necessary to maintain circulatory volume and should not be restricted in the diet. Excessive walking is contraindicated; too much walking may increase general arteriolar spasm. Fluid restriction is contraindicated, and, because of the increased circulatory volume during pregnancy, the client needs 2000 mL of fluid per day.
The nurse is providing care to a client with preeclampsia who is receiving magnesium sulfate 2 g/hr. The nurse receives a call from the laboratory technician indicating that the client has a magnesium level of 6.4 mEq/L (0.30 mmol/L). What is the next nursing action? 1 Stopping the infusion 2 Assessing the client's deep tendon reflexes 3 Assessing the client's level of consciousness 4 Documenting the level in the client's electronic medical record
4 Documenting the level in the client's electronic medical record Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. The therapeutic range for magnesium for the preeclamptic client is 4 to 7 mEq/L (0.28 to 0.44 mmol/L). The nurse must constantly assess the client for a toxic level of magnesium, which can depress the central nervous system and slow the respiratory rate, alter the level of consciousness, and cause deep tendon reflexes to diminish or disappear.
A 36-year-old primigravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, which nursing intervention is of the highest importance at this time? 1 Assessing the fetal heart rate for tachycardia 2 Promoting adequate urine output by offering oral fluids 3 Monitoring respiratory status and ascertaining that calcium gluconate is at the bedside 4 Notifying the primary healthcare provider regarding the epigastric pain, headache, and blurred vision
4 Notifying the primary healthcare provider regarding the epigastric pain, headache, and blurred vision Epigastric pain, blurred vision, and headache are prodromal symptoms of eclampsia in a client with preeclampsia. Minimal urine output in 8 hours would be 240, or 30 mL/hr. The risk for a tonic-clonic seizure increases dramatically, and death is possible. Because the client is receiving a central nervous system depressant, it is more likely that the fetal heart rate will be decreased. The client is usually on nothing-by-mouth status during magnesium sulfate administration, particularly with unstable clinical findings, because of the possible need for an emergency cesarean birth. Although it is important to monitor the client's respirations and to ensure that calcium gluconate (magnesium sulfate antagonist) is available, neither is the priority in a life-threatening situation.
