Nokea
A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient's magnesium level is 7.6 mg/dL. What is the nurse's priority action?
- A. Stop the infusion of magnesium.
- B. Assess the patient's respiratory rate.
- C. Assess the patient's deep tendon reflexes.
- D. Notify the health care provider of the magnesium level.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's respiratory rate. A magnesium level of 7.6 mg/dL is above the therapeutic range (4-7 mg/dL) and can lead to magnesium toxicity. Respiratory depression is a common early sign of magnesium toxicity. Assessing the patient's respiratory rate is the priority to monitor for this potentially life-threatening complication. Stopping the infusion of magnesium (Choice A) is not the immediate priority as the patient's respiratory status needs to be assessed first. Assessing deep tendon reflexes (Choice C) is important for magnesium toxicity but not as urgent as assessing respiratory rate. Notifying the health care provider (Choice D) can be done after assessing the patient's respiratory rate.
You may also like to solve these questions
What is the difference between a complete abortion and an incomplete abortion?
- A. In a complete abortion, the uterus is empty, while in an incomplete abortion, some products of conception are still present in the uterus.
- B. In a complete abortion, the cervix dilates, while in an incomplete abortion, the cervix remains closed.
- C. In a complete abortion, the patient experiences minimal to no signs or symptoms of miscarriage, while in an incomplete abortion, the patient experiences persistent bleeding, cramping, or abdominal pain.
- D. In a complete abortion, the fetus is delivered through the birth canal, while in an incomplete abortion, the fetus is removed through medical or surgical intervention.
Correct Answer: A
Rationale: The correct answer is A because in a complete abortion, the uterus is empty, indicating that all products of conception have been expelled. In contrast, in an incomplete abortion, some products of conception remain in the uterus, leading to ongoing bleeding and cramping. Choice B is incorrect because cervical dilation is not the defining factor between complete and incomplete abortions. Choice C is incorrect as both complete and incomplete abortions can present with symptoms of miscarriage. Choice D is incorrect because the method of fetal removal does not differentiate between complete and incomplete abortions.
The nurse receives a phone call from a patient at 36 weeks' gestation who states they are having right upper quadrant pain that penetrates to the upper back. What priority information does the nurse need to obtain from the patient? Select 3 that apply.
- A. onset and characteristics of the pain
- B. any nausea or vomiting
- C. any vaginal discharge
- D. content of last meal
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A is important to determine the onset and characteristics of the pain to assess for possible causes like pre-eclampsia. B is crucial to assess for signs of liver or gallbladder issues. C is important to rule out any potential infection like chorioamnionitis. D is not relevant to the presenting symptoms and does not provide information related to the patient's condition.
A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action?
- A. Administering oxygen
- B. Elevating the head of the bed
- C. Drawing blood for a hematocrit level
- D. Giving an intramuscular analgesic
Correct Answer: A
Rationale: The correct immediate nursing action is to administer oxygen (Choice A) to ensure adequate oxygenation for both the mother and the fetus. Oxygen is crucial in cases of vaginal bleeding as it helps maintain tissue perfusion and prevent hypoxia. Elevating the head of the bed (Choice B) is not the priority as oxygenation should be addressed first. Drawing blood for a hematocrit level (Choice C) may provide valuable information but does not address the immediate need for oxygen. Giving an intramuscular analgesic (Choice D) is not appropriate without knowing the cause of the pain and bleeding.
Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae?
- A. Saturated perineal pad in 1 hour
- B. Pain level 0 on a scale of 0 to 10
- C. Cervical dilation at 2 cm
- D. Fetal heart rate at 160 bpm
Correct Answer: B
Rationale: The correct answer is B because in placenta previa, pain is usually minimal or absent, while in abruptio placentae, there is severe abdominal pain. Saturated perineal pad (choice A) is common in both conditions. Cervical dilation (choice C) is not specific to differentiate between the two conditions. Fetal heart rate (choice D) may be normal in both conditions.
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
- A. immediate birth is required.
- B. the patient should be transferred to the critical care unit for closer observation.
- C. RhoGAM should be administered.
- D. a tetanus shot should be administered.
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The positive Kleihauer–Betke test indicates fetal-maternal hemorrhage, where fetal blood enters the maternal circulation. This can lead to fetal-maternal transfusion, causing fetal anemia. Immediate birth is necessary to assess and manage potential fetal distress, such as anemia and hypoxia, due to the trauma from the MVA.
Choices B, C, and D are incorrect:
B: Transferring to critical care unit is not the immediate priority. The focus should be on addressing the fetal distress.
C: RhoGAM is given to Rh-negative mothers to prevent Rh sensitization, but it is not directly related to the positive Kleihauer–Betke test result.
D: Tetanus shot administration is important for tetanus prevention, but it is not the priority in this case where immediate birth is required due to fetal-maternal hemorrhage.