1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to

ease the nausea and vomiting. The nurse tells the client to:

A. Eat foods high in calories and fat

B. Lie down for at least 20 minutes after meals

C. Eat carbohydrates such as cereals, rice, and pasta Correct

D. Consume primarily soups and liquids at mealtimes

A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to

prevent eclampsia. Which finding indicates to the nurse that the medication is effective?

E. Clonus is present. Incorrect

F. Magnesium level is 10 mg/dL.

G. Deep tendon reflexes are absent.

H. The client experiences diuresis within 24 to 48 hours. Correct

A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits

signs of magnesium toxicity. The nurse immediately prepares for the administration of:

I. Vitamin K

J. Protamine sulfate Incorrect

K. Calcium gluconate Correct

L. Naloxone hydrochloride

Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the

effects of magnesium at the neuromuscular junction. It should be readily available whenever

magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the

administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the

Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within

24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is

increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid

rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is

sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is

normally not present. The therapeutic magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to

2+ but should not be absent.

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