Health Promotion and Maintenance
76. A client, gravida 2, para 0, is admitted to a labor and delivery unit at 35 weeks' gestation. Her blood pressure is 180/110 mm Hg, pulse 88, respirations 18, and temperature 98.6°F. Her urine dipstick shows 3+ proteinuria and a physical assessment reveals 3+ deep tendon reflexes. A physician orders magnesium sulfate to be infused at 2 gm/hr. Which action by a nurse indicates understanding of the possible side effects of magnesium sulfate?
. Placing a sign over the bed not to check blood pressure in the right arm.
. Placing a padded tongue blade at the bedside.
. Inserting a Foley catheter.
. Darkening the room.
Test-Taking Tip
This question is asking about the side effects of magnesium sulfate and not about treatments for preeclampsia. Eliminate the options that do not treat side effects.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Interactions
Health Promotion and Maintenance
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Answer 1 is incorrect because checking the blood pressure in the right arm has no association with the side effects of magnesium sulfate. Answer 2 is incorrect because this intervention is contraindicated in a seizure. It acts to occlude the airway and prevent proper ventilation. Answer 3 is incorrect because inserting a Foley catheter is not associated with any side effects of magnesium sulfate. It may be used to carefully measure output and signs of worsening preeclampsia, but not for side effects of magnesium sulfate. Answer 4 is correct because magnesium sulfate side effects include headaches and seizures. Darkening the room can help reduce the occurrence of these side effects.