ATI real life
preeclampsia Scenario
Nurse Morgan calculates the dosage of hydralazine (Apresoline).
Question
Nurse Morgan is preparing to administer hydralazine (Apresoline) 5 mg IV bolus. Available
is hydralazine 20 mg/mL. How many mL should Morgan administer? (Round the answer to
the nearest hundredth.)
Selected Option
0.25
Rationale
STEP 1: What is the unit of measurement to calculate?
mL
STEP 2: What is the dose needed? Dose needed = Desired.
5 mg
STEP 3: What is the dose available? Dose available = Have.
20 mg
STEP 4: Should the nurse convert the units of measurement?
No
STEP 5: What is the Quantity of the dose
available? 1 mL
STEP 6: Set up the equation and solve for X.
Have = Desired
Quantity X
20 mg = 5 mg
1 mL X mL
X = 0.25
STEP 7: Round, if necessary.
STEP 8: Reassess to determine the amount to administer makes sense. If there are 20 mg/mL
and the amount prescribed is 5 mg, it makes sense to administer 0.25 mL. The nurse should
administer hydralazine 0.25 mL IV.
Nurse Morgan is preparing to administer magnesium sulfate IV at 2 g/ hr. Available is
magnesium sulfate 40 g/1,000 mL lactated Ringer's. Morgan should set the IV pump to deliver
how many mL/hr? (Round the answer to the nearest whole number.)
Selected Option
50 mL/hr
Rationale
STEP 1: What is the unit of measurement to calculate?
mL/hr
STEP 2: What is the volume
needed? 2 g
STEP 3: What is the total infusion
time? 1 hr
, STEP 4: Should the nurse convert the units of measurement?
No
STEP 5: Set up the equation and solve for X.
Have = Desired
Quantity X
2 g = 40 g
X mL 1,000 mL
X = 50
STEP 6: Round, if necessary.
STEP 7: Reassess to determine the amount to administer makes sense. If the amount
prescribed is 2 g/hr and available is 40 g/1,000 mL, it makes sense to administer 50 mL/hr. The
nurse should set the IV pump to deliver magnesium sulfate at 50 mL/hr.
Scenario
Nurse Morgan assesses Ms. Klein during the administration of IV magnesium sulfate.
Question
Nurse Morgan is administering IV magnesium sulfate to Ms. Klein. Which of the following
manifestations indicates Ms. Klein is experiencing magnesium toxicity?
Selected Option
Respirations 11/min
Rationale
A respiratory rate of less than 12/min is an indication of magnesium toxicity. The nurse should
report this manifestation to the provider.
Scenario
Nurse Morgan recognizes a nonreassuring fetal heart rate.
Question
Nurse Morgan recognizes Ms. Klein is experiencing variable decelerations of the fetal heart rate.
Which of the following nursing interventions should Morgan take at this time?
Selected Option
Change Ms. Klein's position
Rationale
The nurse should change the client's position to a lateral or knee-chest position to attempt to
improve uteroplacental perfusion.
Scenario
Nurse Morgan reviews laboratory test results for Ms. Klein.
Question
Nurse Morgan reviews the laboratory test results for Ms. Klein. Which of the following findings
confirms a diagnosis of severe preeclampsia?
Selected Option
Aspartate aminotransferase (AST) 75
units/L Rationale
This liver enzyme is significantly elevated and is consistent with a diagnosis of severe
preeclampsia.