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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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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.
The nurse is monitoring a client during the first stage of labor. What finding requires immediate intervention?
- A. Contractions every 3–5 minutes.
- B. Baseline fetal heart rate of 110 beats/minute.
- C. Variable decelerations on the fetal monitor.
- D. Client reports back pain during contractions.
Correct Answer: C
Rationale: The correct answer is C because variable decelerations on the fetal monitor indicate umbilical cord compression, which can lead to fetal distress and hypoxia. Immediate intervention is needed to relieve the compression and prevent potential harm to the baby. Contractions every 3-5 minutes (A) are normal in the first stage of labor. A baseline fetal heart rate of 110 beats/minute (B) is within the normal range for a fetus. Client reporting back pain (D) is a common symptom of labor and not necessarily indicative of a complication requiring immediate intervention.
The nurse is teaching a client about preterm labor prevention. What instruction is most appropriate?
- A. Drink at least 8–10 glasses of water daily.
- B. Avoid lying down during the day.
- C. Increase physical activity levels.
- D. Reduce protein intake.
Correct Answer: A
Rationale: The correct answer is A because adequate hydration helps prevent preterm labor by maintaining amniotic fluid levels and preventing dehydration-induced contractions. Drinking 8-10 glasses of water daily ensures proper hydration.
B is incorrect because lying down during the day does not have a direct impact on preterm labor prevention.
C is incorrect as excessive physical activity can sometimes trigger preterm labor instead of preventing it.
D is incorrect as protein intake is important for fetal development and reducing it can lead to nutritional deficiencies, but it is not a direct factor in preventing preterm labor.
Which of the following conditions is concerning to The nurse recognizes which as a risk factor for placenta the infant nursery nurse? abruptio? Select all that apply.
- A. An infant who passes a thick, greenish to black
- B. Use of alcohol stool with each bowel movement
- C. Hypertension
- D. Hard, small, white papules on the face of the
Correct Answer: C
Rationale: Correct Answer: C - Hypertension
Rationale:
1. Hypertension is a known risk factor for placental abruption.
2. Hypertension can lead to poor placental perfusion, increasing the risk of abruption.
3. Proper monitoring and management of hypertension are crucial to prevent adverse outcomes.
Summary:
A, B, D are unrelated to placental abruption and not risk factors. Hypertension is directly linked to placental abruption due to its impact on placental perfusion.
A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
- A. Assess for fetal heart rate changes.
- B. Check maternal vital signs.
- C. Perform a sterile vaginal examination.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.