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A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 11/min.
- B. Deep tendon reflexes 2+.
- C. Urine output 30 mL/hr.
- D. Blood pressure 100/62 mm Hg.
Correct Answer: A
Rationale: A respiratory rate of 11/min is below the normal adult range of 12–20/min and indicates respiratory depression, a potential adverse effect of magnesium sulfate requiring immediate intervention.
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A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The abdomen is the preferred site for subcutaneous heparin injections due to its fatty tissue, which minimizes risks of intramuscular bleeding and ensures consistent drug absorption.
A nurse is assessing a client who gave birth 12 hours ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia.
- B. Flushed face.
- C. Hypotension.
- D. Polyuria.
Correct Answer: C
Rationale: Hypotension, defined as blood pressure below 90/60 mmHg, occurs due to reduced blood volume and cardiac output in excessive postpartum bleeding, impairing adequate perfusion to organs and tissues.
For each of the following potential antihypertensive medications, indicate whether it is recommended or not recommended for use in a pregnant client.
- A. Methyldopa.
- B. Lisinopril.
- C. Labetalol.
- D. Losartan.
- E. Hydralazine.
Correct Answer: A,C,E
Rationale: Methyldopa (A) is safe and effective for pregnancy-induced hypertension. Labetalol (C) is recommended for hypertensive crises with a favorable safety profile. Hydralazine (E) is safe for severe hypertensive emergencies. Lisinopril (B) and Losartan (D) are contraindicated due to teratogenic risks.
A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?
- A. Polyuria.
- B. Hypertension.
- C. Pruritus.
- D. Dry mouth.
Correct Answer: C
Rationale: Pruritus is a frequent side effect of epidural anesthesia, particularly when using opioids like fentanyl, due to histamine release or opioid receptors activation in the spinal cord.
A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicates an understanding of the teaching?
- A. I will need to have the IUD replaced each year.
- B. I will need to apply a spermicide prior to intercourse.
- C. I should expect my periods to stop while I have the IUD.
- D. I should check for the string each month after menstruation.
Correct Answer: D
Rationale: Checking for the string ensures proper IUD positioning and functionality. This monthly practice helps detect dislodgement or expulsion, which can compromise contraceptive effectiveness.