Maryland Next Gen NCLEX Test Bank Project

Maryland Next Gen NCLEX Test Bank Project September 1, 2022

Case Study Topic:

(& stand-alone bow-tie) Pre-Eclampsia with magnesium toxicity Author

:

Christine Schlaerth, PhD, RN, CNM, WHNP-BC Carroll Community College Case Summary A client diagnosed with preeclampsia is admitted at 35 weeks gestation to labor and delivery.Magnesium sulfate is administered for seizure prophylaxis, and magnesium toxicity develops. Learner should recognize s/s of magnesium toxicity and implement appropriate nursing interventions.Objectives 1.Recognize s/s magnesium toxicity 2.Recognize trends and changes in client conditions/vital signs and intervene as needed 3.Provide care for clients experiencing complications of pregnancy/labor and or delivery 4.Evaluate and document actions taken to counteract side effects of medications and parenteral therapies Case Study LinkCase Study QR Code

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SV_eyabT2E95Uker4O Bow-tie QR CodeBow-tie Link

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SV_5svaq0CHkK9aRT0 Case References 1.Agency for Healthcare Research and Quality (2017). Safe medication administration: Magnesium sulfate. Retrieved from: https://www.ahrq.gov/hai/tools/perinatal- care/modules/strategies/medication/tool-safe-mgso4.html 2.Bristol, T.J., Herrman, J.W, and Stephenson, W. (2019). Hypertensive Disorders of Pregnancy. In NurseThink for Students: NCLEX-RN Conceptual Review Guide (pp. 46). NurseTim, Inc.CJCST Version 2.1 designed by Desirée Hensel, 2022. Permission granted to use and modify template for educational purposes. 1 / 2

Case Study Question 1 of 6 The nurse is caring for a client admitted to the labor and delivery unit at 35 weeks gestation with preeclampsia.Click to highlight the 4 findings that are most significant.Admission Note

• Client is a 29-year-old primigravida at 35 weeks gestation admitted with severe preeclampsia. Plan

is magnesium sulfate x 24 hours, followed by induction of labor.Flowsheet Time0900 1000 1100 1200 Magnesium sulfate dose4g 2g 2g 2g Reflexes present Yes +2 Yes +2 Yes +2 No Blood pressure 159/89 139/84 131/85 109/72 Heart rate 72 71 72 102 Respirations 18 18 17 11 Pulse oximetry 99% on RA99% on RA98% on RA92% on RA Urine Output 35ml 30ml 30ml 20ml Other drugs or observations None Nausea Nausea, cutaneous flushing, sweating Shortness of breath

• 4g loading dose magnesium sulfate IV started, to be run over 20 minutes. Second nurse verified

pump settings. Client educated on medication side effects. Client complains of headache rated 7/10, no nausea/vomiting, no epigastric pain, no visual disturbances. Current BP 159/89. Fetal monitor shows baseline heart rate 130 bpm, moderate variability, accelerations present, decelerations absent.

• Magnesium sulfate loading dose complete. Magnesium rate rate changed to 2g/hr continuous

infusions. Second nurse verified pump settings.

• Client noted to have cutaneous flushing and sweating. Fan brought to bedside.
• Absent patellar reflex, RR 11, with complaints of shortness of breath. Pulse oximeter 92% on RA.

Key Flowsheet Time0900 1000 1100 1200 Magnesium sulfate dose4g 2g 2g 2g Reflexes present Yes +2 Yes +2 Yes +2 No Blood pressure 159/89 139/84 131/85 109/72 Heart rate 72 71 72 102 Respirations 18 18 17 11 Pulse oximetry 99% on RA99% on RA98% on RA92% on RA Urine Output 35ml 30ml 30ml 20ml Other drugs or None Nausea Nausea, Shortness of CJCST Version 2.1 designed by Desirée Hensel, 2022. Permission granted to use and modify template for educational purposes.

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