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The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.
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Which client would the nurse identify as being at highest risk for developing complications during pregnancy?
- A. A 17-year-old gravida I client
- B. A client with the placenta implanted on the fundus of the uterus
- C. A client who has nausea and vomiting during the first trimester
- D. A 35-year-old gravida V client
Correct Answer: D
Rationale: A 35-year-old gravida V client is at higher risk due to advanced maternal age and multiple pregnancies, increasing complication risks.
The pregnant client and her significant other are attending childbirth classes. The client asks for guidance on preparing her school-aged child for the new baby’s birth. Which strategies might the nurse suggest that the client use with her child? Select all that apply.
- A. Read books about bringing home a new baby.
- B. Think of unique names for the new baby.
- C. Help pack a bag for bringing the new baby home.
- D. Explain how pregnancy occurred, if asked.
- E. Help the child buy presents for the new baby.
Correct Answer: A,B,C,E
Rationale: Engaging the child in activities such as reading books about bringing the new baby home helps the child to feel a part of the experience. Engaging the child in activities such as naming the new baby helps the child to feel a part of the experience. Engaging the child in activities such as packing a bag for the new baby’s coming home helps the child to feel a part of the experience. Engaging the child in activities such as buying presents for the new baby helps the child to feel a part of the experience. Children younger than adolescents do not fully understand conception and pregnancy due to preoperational and concrete operational thinking. They are not usually asking for an explanation of sex during this time.
The nurse reviews information and assesses the laboring client at 42 weeks’ gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply.
- A. Umbilical cord prolapse
- B. Transverse fetal lie
- C. Cervical dilation not progressing
- D. Premature rupture of membranes
- E. Previous cesarean incision
Correct Answer: A,B,E
Rationale: Inducing labor with an umbilical cord prolapsed can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is a contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP. Lack of progressive cervical dilation is an indication for labor induction, not a contraindication. Premature rupture of the membranes is an indication for labor induction, not a contraindication.
The client presents with vaginal bleeding at 7 weeks. Which action should be taken by the nurse first?
- A. Take the client’s vital signs
- B. Prepare examination equipment
- C. Give 2 liters oxygen per nasal cannula
- D. Assess the client’s response to the situation
Correct Answer: A
Rationale: Assessing the client’s VS should be completed first. Bleeding can cause hypotension. Although preparing examination equipment is important, the nurse should first focus on the client. Having oxygen available is important, but there is no indication that the client needs oxygen at this time. Assessing the client’s response is important, but assessment of physiological problems should occur first.
The 22-year-old client tells the clinic nurse that her last menstrual period was 3 months ago, which began on November 21. She has a positive urine pregnancy test. Using Naegele’s rule, which date should the nurse calculate to be the client’s estimated date of confinement (EDC)?
- A. August 28
- B. January 28
- C. August 15
- D. January 15
Correct Answer: A
Rationale: Naegele’s rule is a common method to determine the EDC. To calculate the EDC, subtract 3 months and add 7 days. This makes the EDC August 28. An EDC of January 28 was calculated by adding 2 months and 7 days. An EDC of August 15 was calculated by subtracting 3 months and 6 days. An EDC of January 15 was calculated by adding 2 months and subtracting 6 days.