Practice Question
Patient's data.
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Correct Answer:
Initiate seizure precautions.
Rationale:
Initiate seizure precautions
🟣 Olivia exhibits severe preeclampsia symptoms, including hypertension, headache, hyperreflexia with clonus, and visual disturbances—all of which increase her risk of eclampsia (seizure).
🟣 Seizure precautions are standard safety measures that include keeping padded side rails up, suction equipment at the bedside, and minimizing external stimuli.
🟣 This intervention is prophylactic, aiming to reduce harm in the event a seizure occurs.
🟣 It is crucial to implement these precautions before initiating magnesium sulfate, as the onset of protection may not be immediate.
🟣 These steps form part of the evidence-based nursing care for severe preeclampsia.
Begin IV magnesium sulfate per protocol
🟣 Magnesium sulfate is the first-line therapy for seizure prophylaxis in patients with severe preeclampsia.
🟣 The ordered dose—4 g loading dose followed by 2 g/hr maintenance—is appropriate and aligns with clinical protocols.
🟣 This medication stabilizes neuromuscular excitability, reducing the chance of seizure activity.
🟣 Magnesium also helps reduce cerebral vasospasm, which contributes to the patient's neurologic symptoms.
🟣 Close monitoring of reflexes, respiratory rate, and urine output is essential during administration to prevent magnesium toxicity.
Insert Foley catheter for strict intake and output monitoring
🟣 Accurate urine output measurement is essential in managing preeclampsia, especially while the patient is on magnesium sulfate, which is renally excreted.
🟣 Decreased urine output is a potential sign of worsening renal function or magnesium toxicity.
🟣 Foley catheterization allows for strict hourly monitoring to ensure urine output stays above 30 mL/hr.
🟣 This data helps guide safe magnesium sulfate titration and fluid balance in a patient at risk for pulmonary edema.
🟣 The order aligns with standard protocol in severe preeclampsia management.
Notify provider of low platelet count
🟣 Olivia’s platelet count is 120,000/mm³, which is below the normal reference range (150,000–400,000/mm³) and signals thrombocytopenia.
🟣 Thrombocytopenia is a severe feature of preeclampsia and can progress to HELLP syndrome.
🟣 Low platelets increase the risk for hemorrhage, especially if delivery or regional anesthesia is planned.
🟣 The healthcare provider must be aware to guide delivery planning and anesthetic precautions.
🟣 Frequent monitoring may be needed to evaluate for further hematologic compromise.
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This question is from Custom: NUR209 SU 2 2025 Midpoint Assessment which contains 36 questions.
More Questions from This Exam
A first-time mother presents for a labor check. She is informed that her vaginal exam shows dilated (3 cm). effaced (10096). and fetal station ( -2). The client asks the nurse to explain the meaning of the results. What explanation is the most appropriate response by the nurse?
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A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
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Olivia Martinez is a 32-year-old G2P1 at 34 weeks and 2 days gestation who presents with a persistent frontal headache and blurry vision that started yesterday.
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Patient's data.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 6