Nokea
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
- A. Respiratory depression
- B. Facial flushing
- C. Nausea
- D. Drowsiness
Correct Answer: A
Rationale: The correct answer is A: Respiratory depression. Respiratory depression is a serious sign of magnesium sulfate toxicity as it can progress to respiratory arrest. Magnesium sulfate acts as a central nervous system depressant, leading to muscle weakness and respiratory depression. Facial flushing is a common side effect but not indicative of toxicity. Nausea and drowsiness are common side effects of magnesium sulfate therapy and are not specific signs of toxicity. Reporting respiratory depression promptly is crucial to prevent further complications.
You may also like to solve these questions
A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
Which teaching is most critical for a mother with gestational diabetes?
- A. Encourage a high-protein diet
- B. Teach the importance of blood glucose monitoring
- C. Advise on the importance of physical activity
- D. Monitor for preterm labor signs
Correct Answer: B
Rationale: The correct answer is B because monitoring blood glucose levels is crucial in managing gestational diabetes to prevent complications for both the mother and baby. By regularly monitoring blood glucose levels, the mother can adjust her diet and insulin intake accordingly to maintain optimal blood sugar levels. This helps in reducing the risk of adverse outcomes such as macrosomia and neonatal hypoglycemia.
Choice A is incorrect because while a balanced diet is important, focusing solely on high-protein intake may not address the specific needs of gestational diabetes management.
Choice C is also important for overall health, but blood glucose monitoring takes precedence in managing gestational diabetes.
Choice D is incorrect as monitoring for preterm labor signs is important in pregnancy but is not directly related to managing gestational diabetes.
A nurse is caring for a patient who discloses they are experiencing family violence. What nursing action should the nurse take to support the patient and promote their safety?
- A. Provide a safe environment for the patient to further disclose their experience.
- B. Converse with the patient’s partner and ask why IPV is occurring in their home.
- C. Report the patient’s accusations to other members of the family.
- D. Propose a plan to leave the abuser today.
Correct Answer: A
Rationale: The correct answer is A: Provide a safe environment for the patient to further disclose their experience. This is the most appropriate action as it prioritizes the patient's safety and well-being. By creating a safe space, the nurse can encourage the patient to share more details about the violence they are experiencing. This can help the nurse assess the situation accurately and provide necessary support and resources.
Choices B, C, and D are incorrect:
B: Conversing with the patient's partner and asking why IPV is occurring is inappropriate as it may put the patient at further risk and breach confidentiality.
C: Reporting the patient's accusations to other family members could worsen the situation and further endanger the patient.
D: Proposing a plan to leave the abuser today may not be feasible or safe without proper assessment and planning.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding?
- A. It connects the pulmonary artery to the aorta.
- B. It is an opening between the right and left atria.
- C. It connects the umbilical vein to the inferior vena cava.
- D. It connects the umbilical artery to the inferior vena cava.
Correct Answer: C
Rationale: The correct answer is C because the ductus venosus is a fetal vessel that connects the umbilical vein to the inferior vena cava, allowing oxygenated blood from the placenta to bypass the liver and flow directly to the fetal heart. Choice A is incorrect because the ductus arteriosus connects the pulmonary artery to the aorta. Choice B is incorrect as it refers to the foramen ovale, which is an opening between the right and left atria. Choice D is incorrect as it describes the ductus deferens, a part of the male reproductive system.
The nurse is assessing a client in the third trimester with suspected placental abruption. What finding supports this diagnosis?
- A. Painless bright red bleeding.
- B. Boardlike abdomen and severe pain.
- C. Soft, relaxed uterus.
- D. Increased fetal movement.
Correct Answer: B
Rationale: The correct answer is B: Boardlike abdomen and severe pain. This finding supports the diagnosis of placental abruption because it indicates a significant and sudden separation of the placenta from the uterine wall, leading to intense pain and rigidity of the abdomen due to internal bleeding. Painless bright red bleeding (choice A) is more indicative of placenta previa, not placental abruption. A soft, relaxed uterus (choice C) is not typical in placental abruption, which usually presents with uterine tenderness and rigidity. Increased fetal movement (choice D) is not specific to placental abruption and can occur in various pregnancy conditions.