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.
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The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.
Which is a disadvantage of the progesterone-only contraception pill?
- A. Side effects could be increased for persons who are underweight.
- B. There could be a decrease in bone mineral density over time.
- C. They may cause irregular bleeding and spotting.
- D. Return to fertility after discontinuing the pill may take several months.
Correct Answer: B
Rationale: The correct answer is B: There could be a decrease in bone mineral density over time. Progesterone-only pills have been associated with a potential decrease in bone density, especially with long-term use. This is because progesterone can have a negative impact on calcium absorption, leading to bone weakening.
A: Side effects could be increased for persons who are underweight - This is not a specific disadvantage of progesterone-only pills and can apply to any contraceptive method.
C: They may cause irregular bleeding and spotting - This is a common side effect of progesterone-only pills but not a significant disadvantage compared to bone density issues.
D: Return to fertility after discontinuing the pill may take several months - This is a temporary effect and not a long-term disadvantage like decreased bone density.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn's initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn during this procedure to prevent the spread of infection. The umbilical cord stump is a potential entry point for bacteria, so gloves are necessary to maintain asepsis.
A: Assisting a mother with breastfeeding does not require gloves as it is a clean procedure.
B: Performing a newborn's initial bath does not require gloves unless there are open wounds on the newborn.
C: Administering the measles, mumps, rubella vaccine may require gloves, but the primary concern is needlestick safety rather than infection control through glove use.
One goal of Healthy People 2030 is to improve pregnancy planning and prevent unintended pregnancy. What is a negative outcome related to unintended pregnancy that is related to this HP goal?
- A. lost jobs related to inabilities to continue to work
- B. depression and anxiety
- C. increased BMI and unintentional weight gain
- D. increased health-care costs in the United States
Correct Answer: B
Rationale: The correct answer is B: depression and anxiety. Unintended pregnancies can lead to mental health issues like depression and anxiety due to the emotional, financial, and social stress associated with unplanned parenthood. This aligns with the goal of Healthy People 2030 to improve pregnancy planning. Choice A is incorrect because while lost jobs can be a consequence of unintended pregnancy, it is not directly related to the mental health aspect targeted by this HP goal. Choice C is incorrect as increased BMI and weight gain are not typically cited as negative outcomes directly related to unintended pregnancy prevention. Choice D is incorrect as while unintended pregnancies can lead to increased healthcare costs, it does not specifically address the mental health aspect targeted by the HP goal.
Which is a priority nursing intervention for a post-operative patient who has had an incomplete abortion?
- A. Insertion of IV line and fluid replacement
- B. Methergine IM (Clerie said this one to diminish bleeding, but Quizlet said bolded answer)
- C. Positioning client on left side
- D. Preop teaching for surgery
Correct Answer: A
Rationale: The correct answer is A: Insertion of IV line and fluid replacement. This is the priority nursing intervention for a post-operative patient with an incomplete abortion because fluid replacement is essential to address potential hypovolemia from bleeding. Ensuring adequate IV access allows for prompt administration of fluids and medications to stabilize the patient's condition. Choice B, Methergine IM, may help reduce bleeding but is not the immediate priority. Choice C, positioning the client on the left side, is not as urgent as fluid replacement. Choice D, preop teaching for surgery, is not relevant in this post-operative scenario.