Nokea
A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?
- A. Assess maternal blood glucose.
- B. Discontinue the magnesium infusion.
- C. Prepare for an emergency cesarean birth.
- D. Place the client in Trendelenburg position.
Correct Answer: B
Rationale: Correct Answer: B - Discontinue the magnesium infusion.
Rationale: A respiratory rate of 10/min indicates respiratory depression, a common adverse effect of magnesium sulfate. Discontinuing the infusion is crucial to prevent further respiratory compromise and potential respiratory arrest. This action takes precedence over other interventions as it addresses the immediate risk to the client's safety.
Summary of other choices:
A: Assessing maternal blood glucose is unrelated to the client's respiratory rate and immediate need for intervention.
C: Emergency cesarean birth is not indicated based solely on the respiratory rate and magnesium sulfate administration.
D: Placing the client in Trendelenburg position is not appropriate for respiratory depression and may worsen the situation.
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A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care?
- A. Monitor blood glucose levels.
- B. Monitor intake and output.
- C. Monitor weight.
- D. Monitor axillary temperature.
Correct Answer: A
Rationale: The correct answer is A: Monitor blood glucose levels. Newborns who are small for gestational age (SGA) are at risk for hypoglycemia due to inadequate glycogen stores. Monitoring blood glucose levels is crucial to detect and manage hypoglycemia promptly. Monitoring intake and output (B) is important but not the priority in this case. Monitoring weight (C) is essential for assessing growth but does not directly address the immediate risk of hypoglycemia. Monitoring axillary temperature (D) is important for detecting infection or hypothermia but does not address the specific needs of an SGA newborn.
A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?
- A. Large amount of vaginal bleeding
- B. Uterine enlargement greater than expected for gestational age
- C. Severe nausea and vomiting
- D. Unilateral, cramp-like abdominal pain
Correct Answer: D
Rationale: The correct answer is D. Unilateral, cramp-like abdominal pain is a classic symptom of an ectopic pregnancy. This pain occurs due to the fallopian tube stretching or rupturing as the embryo grows. This is different from a normal intrauterine pregnancy, where the pain would be central or bilateral.
A: Large amount of vaginal bleeding is not a typical symptom of an ectopic pregnancy.
B: Uterine enlargement greater than expected for gestational age would be seen in a normal intrauterine pregnancy, not an ectopic pregnancy.
C: Severe nausea and vomiting are common symptoms of early pregnancy but are not specific to ectopic pregnancy.
In summary, the key to identifying an ectopic pregnancy is recognizing the combination of abdominal pain and the location of the pain.
A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?
- A. Bowel sounds
- B. Respiratory rate
- C. Temperature
- D. Fetal heart rate (FHR)
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. Magnesium sulfate is a medication that can cause respiratory depression. Monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress or depression promptly. This assessment is a priority because respiratory depression can lead to serious complications, including respiratory arrest. Assessing bowel sounds (choice A), temperature (choice C), and fetal heart rate (choice D) are important but not as critical as monitoring the respiratory rate when administering magnesium sulfate. Bowel sounds may indicate gastrointestinal motility issues, temperature changes may indicate infection, and fetal heart rate is important in pregnancy but not the priority when administering magnesium sulfate.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?
- A. Accidental lacerations
- B. Respiratory distress
- C. Hypothermia
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Respiratory distress. The nurse's priority is to ensure the newborn's ability to breathe effectively. Respiratory distress is common after cesarean delivery due to fluid in the lungs. Addressing this promptly is critical to prevent complications. Accidental lacerations (A) are important but not immediately life-threatening. Hypothermia (C) can be addressed after ensuring the newborn's respiratory status. Acrocyanosis (D) is a common finding in newborns and not an urgent concern.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use.
- B. Blunt force trauma.
- C. Hypertension.
- D. Cigarette smoking.
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption due to the increased pressure on the placenta, leading to separation from the uterine wall. Cocaine use (A) and cigarette smoking (D) can also increase the risk but are not as common as hypertension. Blunt force trauma (B) can cause a sudden separation of the placenta but is less common compared to hypertension in a routine prenatal setting.