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A healthcare provider is assessing a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. Which of the following findings indicates magnesium toxicity?
- A. Tachycardia
- B. Hyperreflexia
- C. Respiratory rate of 10/min
- D. Polyuria
Correct Answer: C
Rationale: Corrected Rationale: Magnesium sulfate can cause respiratory depression, leading to a decreased respiratory rate. A respiratory rate of 10/min is abnormally low and indicates magnesium toxicity. Tachycardia (Choice A) is not typically associated with magnesium toxicity. Hyperreflexia (Choice B) is a common sign of magnesium toxicity. Polyuria (Choice D) is not a typical finding of magnesium toxicity.
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A nurse is assessing a newborn who was delivered 6 hours ago. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 70/min
- B. Vernix caseosa covering the skin
- C. Milia on the bridge of the nose
- D. Acrocyanosis of the extremities
Correct Answer: A
Rationale: A respiratory rate of 70/min in a newborn is above the expected range and may indicate respiratory distress, which should be reported to the provider. Choice B, vernix caseosa covering the skin, is a normal finding in newborns and does not require reporting. Choice C, milia on the bridge of the nose, is also a common finding in newborns and does not require immediate reporting. Choice D, acrocyanosis of the extremities, is a common finding within the first few hours of life in newborns and typically resolves on its own, so it does not need to be reported.
A nurse is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Client reports constipation
- B. Client reports swelling in the face
- C. Client reports heartburn
- D. Client reports frequent urination
Correct Answer: B
Rationale: The correct answer is B because facial swelling can indicate preeclampsia, a serious condition during pregnancy that requires immediate medical attention. Constipation (choice A), heartburn (choice C), and frequent urination (choice D) are common discomforts during pregnancy and are not typically indicative of a serious complication like preeclampsia at 32 weeks of gestation.
A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?
- A. Feed the newborn on demand
- B. Apply warm compresses to the breast before feeding
- C. Massage the breast after feedings
- D. Ensure the newborn empties one breast before switching to the other
Correct Answer: D
Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.
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 healthcare provider is assessing a newborn who is 12 hours old. Which of the following findings should the provider report?
- A. Respiratory rate 50/min
- B. Blood glucose 30 mg/dL
- C. Blood pressure 60/40 mm Hg
- D. Heart rate 140/min
Correct Answer: B
Rationale: A blood glucose level of 30 mg/dL in a newborn is significantly low and indicates hypoglycemia, which can be dangerous in a newborn. Hypoglycemia in a newborn can lead to neurological issues and requires immediate attention. The other findings provided, such as a respiratory rate of 50/min, blood pressure of 60/40 mm Hg, and a heart rate of 140/min, are within normal ranges for a newborn and do not require immediate reporting unless accompanied by clinical signs of distress.