Examkin

Question

Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse on an obstetrical unit has just received change-of-shift report for four assigned clients. Which client should the nurse assess first?

  1. A client at 35 weeks gestation receiving a continuous magnesium sulfate infusion who has absent deep tendon reflexesAnswer
  2. B
    A client who is 12 hours postpartum following a cesarean birth, reporting incisional pain rated as 8 on a 0 to 10 scale
  3. C
    A client at 39 weeks gestation in active labor whose electronic fetal heart rate tracing reveals consistent early decelerations
  4. D
    A client who is 2 hours postpartum and has a firm uterine fundus that is palpated deviated to the right of the umbilicus

Answer

The client receiving a continuous magnesium sulfate infusion who has absent deep tendon reflexes requires immediate assessment.
The correct answer identifies a client exhibiting absent deep tendon reflexes while on a magnesium sulfate infusion. This is a primary clinical indicator of magnesium toxicity, a severe complication that can rapidly progress to respiratory depression, paralysis, and cardiac arrest. This client is the most unstable and represents a medical emergency requiring immediate assessment, discontinuation of the infusion, and potential administration of calcium gluconate.

Step-by-Step Solution

1
Analyze the clinical situation for each client using the ABCs (Airway, Breathing, Circulation) and safety frameworks.
Identify which client has an actual or potential life-threatening physiological complication.
To determine the highest priority client requiring immediate nursing assessment and intervention.
2
Evaluate the clinical significance of absent deep tendon reflexes in a client receiving magnesium sulfate.
Recognize this finding as a classic, early indicator of magnesium sulfate toxicity.
Absent reflexes often precede life-threatening respiratory depression and cardiac arrest, requiring immediate cessation of the infusion and administration of the antidote, calcium gluconate.
3
Compare the urgency of the remaining clients against the client with magnesium toxicity.
Determine that severe incisional pain, early decelerations, and a full bladder displacing a firm fundus are expected, benign, or lower-priority findings.
While these conditions require nursing action or medication administration, they do not pose an immediate, life-threatening airway or breathing risk.

Key Concept

Prioritization of Care: Recognizing Magnesium Sulfate Toxicity
Rate this question

Topics

Ante/Intra/Postpartum and Newborn Care

More questions from this topic