Difficulty: Medium
Average Score: 91%
Simulated
Passage / Scenario
A 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
A
Rationale
The correct action is to discontinue the medication infusion (Choice A) because it is a priority to stop any potential harm caused by the medication. Continuing the infusion could lead to adverse effects on the client. Choice B is incorrect as there is no indication for an emergency cesarean birth based on the information provided. Choice C, placing the client in Trendelenburg position, is not recommended without a clear indication as it can have negative effects. Choice D, assessing maternal blood glucose, is important but not as urgent as discontinuing the medication infusion. Therefore, the correct course of action is to prioritize the immediate discontinuation of the medication infusion to ensure client safety.