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    Ati rn vati comprehensive predictor proctored exam

    A nurse is planning care for a client who has preeclampsia with severe features and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse plan to include?

    Explanation & Rationale

    A. Administer terbutaline subcutaneously as needed for contractions: Terbutaline is a tocolytic used to suppress preterm labor, not to manage preeclampsia or magnesium sulfate therapy. Its use is unrelated to the care of a client receiving magnesium sulfate for seizure prophylaxis. B. Monitor the client's blood pressure every 2 hr: In severe preeclampsia, blood pressure should be monitored more frequently than every 2 hours—typically every 15–30 minutes initially—because rapid changes can occur, and close monitoring is critical to prevent complications. C. Place suction equipment at the client's bedside: Magnesium sulfate can cause respiratory depression as a serious adverse effect. Having suction equipment readily available ensures immediate intervention if the client experiences decreased respiratory effort or airway compromise, making this an essential safety measure. D. Notify the provider of a urinary output of less than 50 mL/hr: While low urine output can indicate magnesium accumulation or renal impairment, the typical threshold for concern is less than 30 mL/hr. Although monitoring output is important, immediate bedside readiness for respiratory support is the priority intervention when administering magnesium sulfate.

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