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

Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta

provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and

other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting

upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong

odors should be eliminated from the diet, because food smells often incite nausea.

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

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.

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