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A nurse is assessing a client who is at 34 weeks of gestation and is receiving magnesium sulfate for severe preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 10/min
- B. Urine output of 30 mL/hr
- C. Deep tendon reflexes 2+
- D. Client reports feeling warm
Correct Answer: A
Rationale: A respiratory rate of 10/min is significantly low and indicates potential magnesium toxicity, which can lead to respiratory depression. This finding should be reported to the provider immediately for further evaluation and management. Urine output of 30 mL/hr is within the expected range during magnesium sulfate therapy and does not require immediate reporting. Deep tendon reflexes 2+ are a normal finding and do not indicate any immediate concerns. The client reporting feeling warm is a common side effect of magnesium sulfate and does not require immediate reporting unless accompanied by other symptoms.
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A nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 80/50 mm Hg
- B. Uterine contractions
- C. Urine output 150 mL in 2 hours
- D. Client reports cramping
Correct Answer: A
Rationale: The correct answer is A: 'Blood pressure 80/50 mm Hg.' Hypotension can be a side effect of oxytocin administration. A blood pressure of 80/50 mm Hg should be reported to the provider. Choice B, 'Uterine contractions,' is an expected finding as oxytocin is used to stimulate uterine contractions. Choice C, 'Urine output 150 mL in 2 hours,' is within the expected range postpartum. Choice D, 'Client reports cramping,' is a common finding due to uterine contractions and is not a cause for concern unless excessive or severe.
A nurse is providing prenatal education to a client who is in the second trimester of pregnancy. Which of the following statements should the nurse include?
- A. You should expect to feel your baby move at 12 weeks.
- B. You will need to increase your calcium intake during pregnancy.
- C. You should avoid exercise during the second trimester.
- D. You will need to limit your intake of folic acid during pregnancy.
Correct Answer: B
Rationale: The correct answer is B. Calcium intake is crucial during pregnancy to support fetal bone development. The nurse should educate the client to increase their calcium intake. Choice A is incorrect because fetal movements are usually felt around 18-25 weeks, not at 12 weeks. Choice C is incorrect as exercise is generally encouraged during pregnancy, including the second trimester, as long as it is not high-impact or risky. Choice D is incorrect as folic acid intake is essential during pregnancy to prevent neural tube defects, and pregnant individuals are usually advised to increase their folic acid intake.
A nurse is providing discharge teaching to a client who is postpartum and has a prescription for ibuprofen for perineal pain. Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach.
- B. Take the medication only at bedtime.
- C. Take the medication with food.
- D. Take the medication with caffeine.
Correct Answer: C
Rationale: The correct answer is C: 'Take the medication with food.' Ibuprofen can cause gastrointestinal upset, so it is essential for the client to take the medication with food to minimize this side effect. Choice A, 'Take the medication on an empty stomach,' is incorrect because ibuprofen should be taken with food to prevent stomach irritation. Choice B, 'Take the medication only at bedtime,' is incorrect as there is no specific timing requirement for ibuprofen administration related to bedtime. Choice D, 'Take the medication with caffeine,' is incorrect as there is no benefit in combining ibuprofen with caffeine, and caffeine could potentially worsen gastrointestinal side effects.
A nurse is providing care to a client who is in active labor. The nurse observes variable decelerations in the fetal heart rate. Which of the following actions should the nurse take first?
- A. Administer oxygen at 10 L/min via face mask
- B. Reposition the client from side to side
- C. Increase the rate of the IV infusion
- D. Notify the provider
Correct Answer: B
Rationale: The correct action the nurse should take first when observing variable decelerations in the fetal heart rate is to reposition the client from side to side. Variable decelerations are often caused by umbilical cord compression, and repositioning the client can relieve pressure on the cord. Administering oxygen, increasing the IV infusion rate, and notifying the provider can be appropriate actions but repositioning the client takes priority in addressing variable decelerations.
A client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?
- A. This medication will help prevent contractions.
- B. This medication will reduce my baby's risk of respiratory distress.
- C. This medication will prevent early labor.
- D. This medication will increase my baby's weight.
Correct Answer: B
Rationale: Correct answer: Option B. Betamethasone is a glucocorticoid used to promote fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. Option A is incorrect because betamethasone does not prevent contractions. Option C is incorrect as betamethasone does not prevent early labor but helps improve fetal lung development. Option D is incorrect as betamethasone does not increase the baby's weight.