Nokea
The nurse is monitoring a client receiving magnesium sulfate for preeclampsia. What finding indicates the need to discontinue the infusion?
- A. Urine output of 50 mL/hour.
- B. Respiratory rate of 10 breaths per minute.
- C. Blood pressure of 140/90 mmHg.
- D. Deep tendon reflexes +3.
Correct Answer: B
Rationale: A respiratory rate below 12 breaths per minute is a sign of magnesium sulfate toxicity, requiring immediate discontinuation.
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On admission to the nursery, a newborn is observed to be experiencing cold stress. The basis for the nursing intervention at this time would be to minimize:
- A. Shivering
- B. Hyperglycemia
- C. Oxygen consumption
- D. Metabolism of fat stores
Correct Answer: A
Rationale: Shivering increases oxygen demand.
What should the nurse advise the client regarding Depo-Provera (medroxyprogesterone acetate)?
- A. Take the pill at the same time each day.
- B. Refrain from breastfeeding while using the method.
- C. Expect to have no periods as long as she takes the medicine.
- D. Consider switching to another birth control method in a year or so.
Correct Answer: B
Rationale: Depo-Provera can reduce milk supply and thus breastfeeding should be avoided.
The nurse is teaching a prenatal class about signs of labor. Which statement indicates the need for further teaching?
- A. True labor contractions increase in intensity and regularity.
- B. The baby dropping is a sign of true labor.
- C. False labor contractions often stop with activity.
- D. True labor results in cervical changes.
Correct Answer: B
Rationale: Lightening, or baby dropping, occurs weeks before labor and is not a sign of true labor.
What advice should the nurse give a woman taking Fosamax (alendronate) for osteoporosis?
- A. Remain upright for 30 minutes after taking the medication.
- B. Take only after eating a full meal.
- C. Take medication in divided doses 3 times each day.
- D. Do not break or crush the tablet.
Correct Answer: A
Rationale: Remaining upright prevents esophageal irritation.
What physical findings would the nurse expect to see in a woman diagnosed with primary syphilis?
- A. Cluster of vesicles.
- B. Pain-free lesion.
- C. Macular rash.
- D. Foul-smelling discharge.
Correct Answer: B
Rationale: A pain-free chancre is characteristic of primary syphilis.