QUESTION: "The physician orders 5% dextrose in Ringer's solution and magnesium sulfate intravenously for an adolescent client with pregnancy-induced hypertension (PIH). Before the magnesium sulfate is administered, which of the following assessments would be the priority? "
CHOICES
( X ) a.) Fetal heart rate variability.
( X ) b.) Maternal urinary output.
( X ) c.) Fetal position.
( O ) d.) Maternal respiratory rate.
RATIONALE: Magnesium sulfate is a central nervous system depressant used as an anticonvulsant for severe PIH. It may depress respirations to a dangerously low and even life-threatening level. Therefore, the nurse must assess the client's respiratory rate before administering the drug. If the client's respiratory rate is below 12 to 14 breaths/minute, the physician should be notified and the drug should be withheld. Although fetal heart rate variability is an important assessment, it is not the priority assessment in this situation. Fetal heart rate variability would be a priority assessment if the umbilical cord becomes compressed. Although maternal urinary output is an important assessment, it is not the priority assessment in this situation. Assessing maternal urinary output would be a priority after administering magnesium sulfate. Although fetal position, determined by Leopold's maneuvers, is an important assessment, it is not the priority assessment in this situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
