Practice Question
A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)
Answer Choices:
Correct Answer:
Provide a dark, quiet environment.
Rationale:
Provide a dark, quiet environment
♦️Clients with severe gestational hypertension or preeclampsia are at risk for seizures due to increased CNS stimulation.
♦️A calm, low-stimulus environment helps reduce sensory input that may trigger seizures.
♦️This is a standard seizure precaution in hypertensive disorders of pregnancy.
♦️Nurses must minimize noise, bright lights, and unnecessary interruptions in care.
Administer magnesium sulfate IV
♦️ Magnesium sulfate is the anticonvulsant of choice to prevent eclampsia (seizure activity) in clients with severe gestational hypertension or preeclampsia.
♦️It acts as a CNS depressant, stabilizing nerve membranes.
♦️The nurse should monitor for signs of toxicity, including respiratory depression and decreased reflexes.
♦️Administration requires IV pump regulation and frequent monitoring.
Ensure that calcium gluconate is readily available
♦️ Calcium gluconate is the antidote for magnesium sulfate toxicity.
♦️ It should be available at the bedside in case of complications such as respiratory arrest or loss of deep tendon reflexes.
♦️The nurse must assess for signs of toxicity frequently during therapy.
♦️Having the antidote on hand is a key component of safe medication administration.
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This question is from Custom: NUR 2463 Exam #2 which contains 20 questions.
More Questions from This Exam
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
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A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
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A nurse is caring for a client who is a primigravida. at term. and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 5