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Client at 31 weeks of gestation receiving magnesium sulfate via continuous IV infusion for preterm labor.
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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Client in active labor with early decelerations of the FHR on the fetal monitor tracing.
A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia.
- B. Uteroplacental insufficiency.
- C. Cord compression.
- D. Head compression.
Correct Answer: D
Rationale: Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions.
Client gave birth 12 hours ago and is experiencing excessive vaginal bleeding.
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.
Client gave birth 1 week ago, states: 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.'
A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression.
- B. Taking-in phase.
- C. Postpartum blues.
- D. Taking-hold phase.
Correct Answer: C
Rationale: Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
Client experiencing preterm labor with a new prescription for terbutaline.
A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for administration of this medication?
- A. Heart disease.
- B. Cervical dilation of 2 cm.
- C. Gestational age of 34 weeks.
- D. Allergy to penicillin.
Correct Answer: A
Rationale: Terbutaline is contraindicated in heart disease because it can cause tachycardia and arrhythmias, worsening cardiac conditions. Cardiovascular side effects result from its beta-adrenergic agonist action.
Client being admitted for induction of labor.
A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby in any public birth announcements to social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct Answer: A
Rationale: Checking the identification badge ensures the individual removing the baby is authorized, reducing the risk of abduction. This is a recommended safety practice in hospital settings to protect newborns.