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A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider?
- A. Blood pressure 148/94mm Hg
- B. Respiratory rate 14mm
- C. Urinary output 20 mL/hr
- D. 2+deep tendon reflexes
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 148/94mm Hg. High blood pressure in a client with preeclampsia indicates worsening condition and potential for eclampsia. Magnesium sulfate is given to prevent seizures, so high blood pressure needs immediate provider attention.
Incorrect Choices:
B: Respiratory rate 14mm - This respiratory rate is within normal range.
C: Urinary output 20 mL/hr - Low urinary output should be monitored but is not the priority in this situation.
D: 2+deep tendon reflexes - Normal deep tendon reflexes are expected with magnesium sulfate therapy.
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In planning sex education classes for the middle school age group, more emphasis should be placed on
- A. how to set limits for sexual behavior.
- B. the inaccuracy of information from peers.
- C. the use of oral contraceptives to prevent unwanted pregnancy.
- D. the use of condoms to prevent sexually transmitted diseases as well as pregnancy.
Correct Answer: D
Rationale: The correct answer is D because emphasizing the use of condoms is crucial for preventing both sexually transmitted diseases and pregnancy among middle school students who may engage in sexual activity. Condoms are the most effective method for dual protection at this age. Choice A focuses on setting limits but may not address the practical aspect of protection. Choice B is important but not as critical as ensuring proper protection. Choice C is not suitable for this age group due to legal and ethical considerations.
A client in her third trimester complains of Braxton
- A. Report any stools that appear to have milk Hicks contractions. Which of the following interven- curds immediately to the infant's health care tions would help with this type of pain? Select all that provider. apply.
- B. Stools will change from green to yellowish brown
- C. Drink four to six glasses of water per day. to golden yellow over the next several days.
- D. Rest until the contractions subside.
Correct Answer: D
Rationale: The correct answer is D: Rest until the contractions subside. During Braxton Hicks contractions, rest can help alleviate the discomfort. It allows the body to relax and reduces the intensity of the contractions. Other options are incorrect because:
A: Reporting stools with milk curds to the infant's healthcare provider is unrelated to Braxton Hicks contractions.
B: Stool color changes are irrelevant to managing Braxton Hicks contractions.
C: Drinking water is important for overall health during pregnancy but does not directly address Braxton Hicks contractions.
The nurse is educating a client about postpartum warning signs. Which symptom requires immediate medical attention?
- A. Increased lochia after breastfeeding.
- B. Perineal discomfort on day 3 postpartum.
- C. Fever of 101°F and foul-smelling lochia.
- D. Mild fatigue and trouble sleeping.
Correct Answer: C
Rationale: The correct answer is C: Fever of 101°F and foul-smelling lochia. This combination indicates a possible infection like endometritis, which can be life-threatening if not promptly treated. Fever is a sign of systemic infection, and foul-smelling lochia suggests an infected uterus. Immediate medical attention is crucial to prevent complications.
A: Increased lochia after breastfeeding is common and not necessarily alarming unless it is excessive or accompanied by other symptoms.
B: Perineal discomfort on day 3 postpartum is expected due to the healing process and does not typically require immediate medical attention.
D: Mild fatigue and trouble sleeping are common postpartum symptoms but do not indicate a medical emergency unless they are severe or persistent.
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.
What do you give for magnesium sulfate toxicity?
- A. Calcium gluconate
- B. Sodium bicarbonate
- C. Furosemide (Lasix)
- D. Vitamin K
Correct Answer: A
Rationale: The correct answer is A: Calcium gluconate. In magnesium sulfate toxicity, high levels of magnesium can lead to muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is given because it antagonizes the effects of magnesium on the neuromuscular system and helps prevent further complications. Sodium bicarbonate (B) is not the correct choice as it is used to treat acidosis, not magnesium toxicity. Furosemide (C) is a diuretic and would not address magnesium toxicity. Vitamin K (D) is used for blood clotting disorders, not for magnesium toxicity.