Nokea
A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)
- A. Respirations less than 12/min
- B. Urinary output less than 25 mL/hr
- C. Decreased level of consciousness
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Magnesium sulfate toxicity can lead to respiratory depression (respirations less than 12/min), decreased urinary output (less than 25 mL/hr), and altered mental status (decreased level of consciousness). Respiratory depression occurs due to the impact of magnesium on the central nervous system. Decreased urinary output is a result of magnesium's effects on renal blood flow. Altered mental status is a common sign of magnesium toxicity affecting brain function. Reporting these signs promptly is crucial to prevent serious complications. The other choices (A, B, C) are incorrect because they are all potential signs of magnesium sulfate toxicity and should be reported.
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A client who is 3 days postpartum is receiving education on effective breastfeeding. Which of the following information should the nurse include?
- A. Your milk will replace colostrum in about 10 days.
- B. Your breasts should feel firm after breastfeeding.
- C. Your newborn should urinate at least 10 times per day.
- D. Your newborn should appear content after each feeding.
Correct Answer: D
Rationale: The correct answer is D: Your newborn should appear content after each feeding. This is important as it indicates the baby is getting enough milk and is satisfied. If the baby appears content, it suggests effective breastfeeding. Choice A is incorrect as milk transition typically occurs within a few days, not 10. Choice B is incorrect as breasts feeling firm is not a reliable indicator of successful breastfeeding. Choice C is incorrect as the number of wet diapers is a better indicator of proper hydration, not just urination frequency.
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
- A. Monitor the client's blood pressure every hour.
- B. Restrict the total hourly intake to 200 mL.
- C. Monitor the FHR continuously.
- D. Administer protamine sulfate for manifestations of toxicity.
Correct Answer: C
Rationale: The correct answer is C: Monitor the FHR continuously. This is essential in preeclampsia as magnesium sulfate can affect fetal heart rate (FHR). Continuous monitoring helps detect any changes promptly.
A: Monitoring blood pressure is important but not as critical as FHR monitoring in this scenario.
B: Restricting total hourly intake to 200 mL is not necessary for magnesium sulfate administration.
D: Administering protamine sulfate is incorrect as it is used for heparin toxicity, not magnesium sulfate toxicity.
A client in a prenatal clinic is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?
- A. This is due to an increase in blood volume.
- B. This is due to pressure from the uterus on the diaphragm.
- C. This is due to the weight of the uterus on the vena cava.
- D. This is due to increased cardiac output.
Correct Answer: C
Rationale: The correct answer is C: This is due to the weight of the uterus on the vena cava. Maternal hypotension during pregnancy can occur when the growing uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop in blood pressure. This compression can lead to decreased blood flow to the brain and other vital organs, resulting in symptoms of hypotension. The other choices are incorrect because:
A: An increase in blood volume during pregnancy typically leads to an increase in blood pressure, not hypotension.
B: Pressure from the uterus on the diaphragm may cause discomfort or shortness of breath but is not the primary cause of maternal hypotension.
D: Increased cardiac output is a normal adaptation in pregnancy to meet the demands of the growing fetus and placenta, but it does not directly cause maternal hypotension.
During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?
- A. Leukorrhea
- B. Supine hypotension
- C. Periodic numbness of the fingers
- D. Decreased urine output
Correct Answer: D
Rationale: The correct answer is D: Decreased urine output. At 26 weeks of gestation, decreased urine output can be a sign of potential complications like preeclampsia or dehydration, which require immediate medical attention to prevent harm to the mother and baby. Leukorrhea (choice A) is a common pregnancy symptom and not typically concerning. Supine hypotension (choice B) is a known issue in pregnancy but usually occurs later in the third trimester due to pressure on the vena cava when lying on the back. Periodic numbness of the fingers (choice C) can be related to carpal tunnel syndrome, which is common in pregnancy but not typically urgent at 26 weeks unless severe and persistent.
A client at 8 weeks of gestation with iron deficiency anemia is prescribed iron supplements. Which beverage should the nurse reinforce the client to take the supplements with for better absorption?
- A. Ice water
- B. Low-fat or whole milk
- C. Tea or coffee
- D. Orange juice
Correct Answer: D
Rationale: The correct answer is D: Orange juice. Vitamin C enhances iron absorption by converting non-heme iron to a more absorbable form. The acidity in orange juice aids in this process. Ice water (choice A) does not contain any nutrients to enhance iron absorption. Low-fat or whole milk (choice B) contains calcium, which can inhibit iron absorption. Tea or coffee (choice C) contains tannins that can also inhibit iron absorption. In summary, orange juice is the best choice due to its vitamin C content that helps improve iron absorption.