Difficulty: Medium
Average Score: 72%
Simulated
Passage / Scenario
A client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absentA nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
Correct answer
D
Rationale
The correct action is to discontinue the medication infusion (choice D). This is because the client is showing signs of magnesium toxicity, including respiratory depression (respiratory rate of 10/min) and absent deep-tendon reflexes. Discontinuing the magnesium sulfate infusion is crucial to prevent further complications such as respiratory arrest or cardiac arrest. Assessing maternal blood glucose (choice A) is not the priority in this scenario. Emergency cesarean birth (choice B) is not indicated based on the information provided. Placing the client in Trendelenburg position (choice C) can worsen the situation by increasing venous return and exacerbating magnesium toxicity.