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A healthcare provider is assisting with the care for a client who has a prescription for magnesium sulfate. The provider should recognize that which of the following are contraindications for the use of this medication? (Select all that apply)
- A. Fetal distress
- B. Cervical dilation greater than 6 cm
- C. Vaginal bleeding
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Magnesium sulfate is contraindicated in cases of fetal distress, cervical dilation greater than 6 cm, and vaginal bleeding. Fetal distress can be worsened by magnesium sulfate, and it can lead to respiratory depression in the newborn. Cervical dilation greater than 6 cm indicates advanced labor, where the risk of uterine atony and postpartum hemorrhage is increased with magnesium sulfate use. Vaginal bleeding may be a sign of placental abruption or other complications, which can be exacerbated by magnesium sulfate. Therefore, all three options are contraindications for the use of magnesium sulfate in this scenario.
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A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, 'I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device.' The nurse should suspect which of the following?
- A. Missed abortion
- B. Ectopic pregnancy
- C. Severe preeclampsia
- D. Hydatidiform mole
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. Given the client's symptoms of right-sided lower quadrant abdominal pain, vaginal bleeding, missed menstrual cycle, and presence of an intrauterine device, these are classic signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, commonly in the fallopian tube, leading to abdominal pain and vaginal bleeding. The other choices are incorrect because:
A: Missed abortion would typically present with cramping, bleeding, and passage of tissue.
C: Severe preeclampsia is characterized by high blood pressure and proteinuria, not the symptoms described.
D: Hydatidiform mole would typically present with vaginal bleeding and uterine enlargement, but not the sharp abdominal pain described.
A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)
- A. Breast tenderness
- B. Urinary frequency
- C. Epistaxis
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. At 6 weeks of gestation, common discomforts include breast tenderness due to hormonal changes, urinary frequency from increased blood flow to kidneys, and epistaxis (nosebleeds) due to increased blood volume and vessel fragility. Therefore, all options are relevant and should be included in the education. Other choices are incorrect because they do not encompass all the common discomforts experienced during early pregnancy.
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 at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
- A. Provide ice chips.
- B. Insert an indwelling urinary catheter.
- C. Administer opioid analgesic medication.
- D. Provide ice chips.
Correct Answer: C
Rationale: The correct action is to administer opioid analgesic medication (Choice C). At 40 weeks gestation with contractions every 3-5 minutes, 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Pain medication is appropriate to manage discomfort during labor. Opioid analgesics can help reduce pain intensity while still allowing the client to remain alert and participate in labor. Ice chips (Choice A and D) are not directly related to pain management in labor. Inserting a urinary catheter (Choice B) is not indicated unless there are specific concerns about bladder distention.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
- A. Palpate the fundus to identify the fetal part.
- B. Determine the location of the fetal back.
- C. Palpate for the fetal part presenting at the inlet.
- D. All of the Above
Correct Answer: D
Rationale: The correct sequence for performing Leopold maneuvers is to first palpate the fundus to identify the fetal part (A), then determine the location of the fetal back (B), and finally palpate for the fetal part presenting at the inlet (C). Choosing option D (All of the Above) is correct because it encompasses all the necessary steps in the correct order to perform Leopold maneuvers effectively. Palpating the fundus helps identify the presenting part, determining the location of the fetal back provides information on the fetal lie, and palpating for the presenting part at the inlet helps confirm the position of the fetus. The other choices are incorrect because they do not provide the complete sequence required for performing Leopold maneuvers accurately.