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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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The nurse is teaching a prenatal class about warning signs in pregnancy. Which symptom should be reported immediately?
- A. Mild swelling in the feet.
- B. Headache unrelieved by rest or medication.
- C. Increased appetite.
- D. Frequent urination.
Correct Answer: B
Rationale: A headache unrelieved by rest or medication may indicate preeclampsia or other serious conditions and should be reported immediately.
The nurse is monitoring a client receiving magnesium sulfate for preeclampsia. What finding indicates magnesium toxicity?
- A. Increased urine output.
- B. Deep tendon reflexes +4.
- C. Respiratory rate of 10 breaths per minute.
- D. Blood pressure of 140/90 mmHg.
Correct Answer: C
Rationale: Respiratory depression is a key sign of magnesium sulfate toxicity and requires immediate intervention.
A client at 35 weeks' gestation with polyhydramnios is being monitored for complications. What condition is the client at increased risk for?
- A. Umbilical cord prolapse.
- B. Placental abruption.
- C. Fetal growth restriction.
- D. Gestational diabetes.
Correct Answer: A
Rationale: Polyhydramnios increases the risk of umbilical cord prolapse due to excessive amniotic fluid and unstable fetal positioning.
What is essential for the nurse to teach a woman who has just had an intrauterine device (IUD) inserted?
- A. Palpate her lower abdomen each month to check the patency of the device.
- B. Remain on bed rest for 24 hours after insertion of the device.
- C. Report any complaints of painful intercourse to the physician.
- D. Insert spermicidal jelly within 4 hours of every sexual encounter.
Correct Answer: C
Rationale: Painful intercourse may indicate IUD displacement or complications.
A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: Frequent feeding aids in bilirubin excretion.