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The nurse is monitoring a client in labor with an epidural. What finding requires immediate intervention?
- A. Blood pressure of 100/60 mmHg.
- B. Fetal heart rate of 90 beats/minute.
- C. Client reports warmth in the lower extremities.
- D. Contractions every 5 minutes.
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate of 90 beats/minute. A fetal heart rate of 90 bpm indicates fetal distress and requires immediate intervention to prevent potential complications. Decreased fetal heart rate can be a sign of fetal hypoxia or distress. The other choices are not as concerning in this context. A blood pressure of 100/60 mmHg is within normal range. The client reporting warmth in the lower extremities is a common side effect of epidural anesthesia. Contractions every 5 minutes may indicate progress in labor but do not require immediate intervention unless associated with fetal distress.
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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.
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.
Preexisting medical conditions like diabetes, hypertension, and autoimmune diseases can impact pregnancy outcomes. What education can the nurse provide?
- A. Your medical condition always gets worse during pregnancy.
- B. Nutrition changes cannot help with fertility.
- C. Maintaining glucose control can increase chances of conceiving.
- D. Autoimmune diseases only affect pregnancy, not infertility.
Correct Answer: C
Rationale: The correct answer is C: Maintaining glucose control can increase chances of conceiving. This is because uncontrolled diabetes can lead to complications during pregnancy, affecting both the mother and the baby. By educating the patient on the importance of managing their glucose levels, the nurse can help improve fertility outcomes.
A: Your medical condition always gets worse during pregnancy - Incorrect. Medical conditions may not always worsen during pregnancy, and managing them properly can lead to positive outcomes.
B: Nutrition changes cannot help with fertility - Incorrect. Nutrition plays a crucial role in fertility, and making appropriate dietary changes can improve the chances of conception.
D: Autoimmune diseases only affect pregnancy, not infertility - Incorrect. Autoimmune diseases can impact fertility as well as pregnancy outcomes, so it is important to address these conditions when trying to conceive.
The nurse is teaching a client about postpartum care. Which statement indicates a need for further teaching?
- A. I will avoid heavy lifting for 6 weeks.
- B. It’s normal to have heavy bleeding for 4 weeks.
- C. I will call my doctor if I develop a fever.
- D. I should continue taking my prenatal vitamins.
Correct Answer: B
Rationale: The correct answer is B because heavy bleeding for 4 weeks postpartum is abnormal and could indicate a complication. The client should seek medical attention if experiencing heavy bleeding beyond the normal range. Choices A, C, and D are all correct statements for postpartum care. A - avoiding heavy lifting helps prevent strain on healing tissues, C - fever could indicate infection, and D - continuing prenatal vitamins supports postpartum recovery.
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to
- A. "You should go ahead and push to assist the delivery."
- B. "You should try to pant as the delivery proceeds."
- C. "You should try to perform slow-paced breathing."
- D. "You should take a deep, cleansing breath and breathe naturally."
Correct Answer: A
Rationale: The correct answer is A because the newborn's head crowning indicates imminent delivery, and the client's urge to push aligns with the natural progression of labor. By encouraging the client to push, the nurse facilitates the safe and timely delivery of the baby. Panting (choice B) or slow-paced breathing (choice C) may not be effective in this advanced stage of labor. Taking a deep cleansing breath (choice D) can delay the delivery and is not recommended when the baby is crowning.