Nokea
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations is an adverse reaction to the medication?
- A. Hypertension
- B. Hypoglycemia
- C. Respiratory rate 16/min
- D. Urine output 20 mL/hr
Correct Answer: D
Rationale: Urine output of 20 mL/hr suggests oliguria, risking magnesium toxicity due to poor renal excretion, unlike hypertension (preeclampsia symptom), hypoglycemia (unrelated), or normal respiratory rate.
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A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
- A. Three fetal movements perceived by the client in a 20 min testing period
- B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min resting period
- C. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period
- D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
Correct Answer: A
Rationale: Only three fetal movements in 20 minutes is below the expected activity level, suggesting possible fetal compromise, unlike reassuring heart rate responses or minor contractions.
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
- A. Decrease in frequency of contractions
- B. BP 150/100 mm Hg
- C. Absent deep tendon reflexes
- D. Urinary output 35 mL/hr
Correct Answer: C
Rationale: Absent deep tendon reflexes indicate magnesium toxicity, a serious complication requiring immediate reporting to prevent further harm, unlike reduced contractions (desired effect), elevated BP (monitor but less urgent), or low-normal urine output.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Transmission can occur via the saliva and urine of the newborn
- B. This infection requires that airborne precautions be initiated for the newborn
- C. Mothers will receive prophylactic treatment with acyclovir prior to delivery
- D. Lesions are visible on the mother's genitalia
Correct Answer: A
Rationale: CMV transmission occurs through newborn saliva and urine, unlike requiring airborne precautions, acyclovir (herpes treatment), or visible genital lesions (not typical).
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?
- A. The client has a fundal height of 38 cm
- B. The client has a fasting blood glucose of 90 mg/dL
- C. The client reports 12 fetal movements in 1 hr
- D. The client has nonpitting pedal edema
Correct Answer: A
Rationale: A fundal height of 38 cm at 32 weeks suggests macrosomia, a gestational diabetes complication, requiring reporting, unlike normal glucose, fetal movements, or edema.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should wash your diaphragm in gentle soap and water after each use
- B. You should keep your diaphragm in place for at least 4 hours after intercourse
- C. You will use an oil-based vaginal lubricant when inserting your diaphragm
- D. You should have a provider refit you for a new diaphragm
Correct Answer: D
Rationale: Postpartum vaginal changes require diaphragm refitting for effectiveness, unlike incorrect washing (correct but not primary), 4-hour retention (6 hours minimum), or oil-based lubricant (damages diaphragm).