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46.A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside?A) Vitamin KB) Protamine sulfateC) Potassium chlorideD) Calcium gluconateANS: DFeedback: CORRECTRationale: Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsiato help prevent seizures (eclampsia). It also causes central nervous system depression, however, sotoxicity is a concern. Calcium gluconate should be available at the bedside of a client receiving anintravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest ifthe serum magnesium level becomes too high. Vitamin K is the antidote for warfarin sodium (Coumadin).Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency.Test-Taking Strategy: Knowledge regarding the antidotes to various medications is needed to answer thisquestion. Use the process of elimination and remember that calcium gluconate is the antidote tomagnesium sulfate. Review care of the client receiving magnesium sulfate if you had difficulty with thisquestion.Reference: Lowdermilk, D., Perry, S., & Cashion, K., (2010). Maternity nursing (8th ed., p. 685). St.Louis: Mosby.
Cognitive Ability: ApplyingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Maternity/IntrapartumPoints Earned: 1.0/1.0Correct Answer(s): D47.A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop pretermlabor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170beats/min. The appropriate action by the nurse is:sympathetic nervous system, resulting in bronchodilation and inhibition of uterine muscle activity. Thenurse monitors the client for adverse effects and notifies the physician if the maternal heart rate is fasterthan 110 beats/min, respiration is faster than 24 breaths/min, systolic blood pressure is less than 90 mmHg, the fetal heart rate is faster than 160 beats/min, or the client complains of chest pain or dyspnea.Increasing the rate of infusion and continuing to monitor the client and are inappropriate and delaynecessary interventions. Although the nurse would document the findings, the most appropriate action inthis scenario is to contact the physician.Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and recallingthe normal maternal heart rate and normal fetal heart rate will direct you to the correct option. Reviewcare of the client receiving terbutaline if you had difficulty with this question.