NRSG207 Nursing Care of Childbearing and Childrearing Families Clinical

NRSG207 Nursing Care of Childbearing and Childrearing Families Clinical

Task:

Labor and delivery with a blinding headache, abdominal pain, and complaints of seeing spots before her eyes.
1.What could be happening to Marly?
2.What places Marly at risk for PIH?
3.Are these symptoms mild or severe?
4.What other data would confirm your suspicions? List critical assessment data:
 
Marly’s VS are BP 160/110, P 120, R 32. She has facial edema and weight gain of 4 pounds since her last visit to the Dr 1 week ago. Urine dip reveals a protein of 3+. The physician orders include a 6 gm bolus of magnesium sulfate in 150cc solution of LR over 30 minutes followed by a 40gm MgSO4 in 1L of LR at 2gm/hr. 
5.Considering her symptoms and prescribed treatments, what specific interventions are necessary to promote safety?
6.What are symptoms of Magnesium Sulfate toxicity?
7.Calculate the milliliters per hour that the maintenance MgSO4 IV will run.
 
Marly has a seizure prior to the administration of the MgSO4 drip. The nurse was only able to start an IV of LR maintenance line and had gone to prepare the drug solution. The nurse returns to find Amy, the PCA, holding a tongue blade in Marly’s mouth.
8.What specific drug is most likely to be given to stop the seizure? What is the effect of this drug?
9.What nursing interventions need to be done immediately?
10.What should the nurse’s initial response to Amy’s actions be? How should the nurse address this issue with Amy later when the patient is out of danger?
11.Considering the patient’s condition, what are the potential sequella for the fetus?

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