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A woman in active labor is receiving intravenous magnesium sulfate for the prevention of eclampsia. What maternal assessment finding indicates magnesium toxicity?
- A. Muscle weakness
- B. Increased deep tendon reflexes
- C. Hypotension
- D. Tachycardia
Correct Answer: B
Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.
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Ms. Ruby 28 year old also a patient of Nurse Gladys is suffering from Rheumatic fever due to a previous streptococcal infection. In monitoring patient's status, the nurse should document which of the following TYPICAL manifestation EXCEPT ______.
- A. Increase body temperature
- B. Voluntary muscle spasm
- C. Non-pruritic rashes
- D. Migratory joint pains
Correct Answer: B
Rationale: In patients with Rheumatic fever, typical manifestations include an increase in body temperature, non-pruritic rashes, and migratory joint pains. Voluntary muscle spasm is not a typical manifestation of Rheumatic fever. The main clinical features of Rheumatic fever are related to the inflammation of the heart, joints, skin, and central nervous system. Muscle spasms are not a prominent feature of this condition. It is important for the nurse to be aware of these typical manifestations to effectively monitor and manage the patient's condition.
The NICU nurse prepares for the arrival of the newborn. Which of the following PRIORITY item should be placed at the newborn's bedside? A _____________.
- A. Specific gravity urinometer
- B. Rectal thermometer
- C. Blood pressure cuff
- D. Bottle of sterile normal saline
Correct Answer: C
Rationale: The priority item that should be placed at the newborn's bedside is a blood pressure cuff. Monitoring the newborn's blood pressure is crucial in the NICU, as it helps assess the baby's cardiovascular function and overall well-being. Blood pressure changes can be an early indication of potential health issues, so having a blood pressure cuff readily available allows for timely monitoring and intervention if necessary. The other items listed (specific gravity urinometer, rectal thermometer, bottle of sterile normal saline) are also important in neonatal care, but monitoring blood pressure takes precedence in this scenario.
A nurse involves well-being in her definition of health. What will the primary concern or focus of the nurse when she provides care to a family confronting the imminent death of a family member?
- A. Reinforcing the need for the whole family to adapt to the impending death.
- B. Sharing the nurse's knowledge on the client's symptoms of grief
- C. Discussing the perceived meaning of life with the family
- D. Administering pain medication so that the client can be kept comfortable
Correct Answer: A
Rationale: When a nurse involves well-being in her definition of health, it indicates a holistic approach that considers not only physical health but also emotional, mental, and social aspects of well-being. In the context of a family confronting the imminent death of a family member, the primary concern of the nurse would be to focus on reinforcing the need for the whole family to adapt to the impending death. This involves providing emotional support, facilitating communication, addressing coping mechanisms, and assisting the family in coming to terms with the situation. By emphasizing the importance of the whole family adapting to the imminent death, the nurse can help promote holistic well-being for the family during this challenging time.
A postpartum client who experienced a traumatic birth expresses concerns about breastfeeding difficulties and emotional distress. What nursing intervention should be prioritized to address the client's concerns?
- A. Providing emotional support and empathy for the client's experience
- B. Recommending cessation of breastfeeding to alleviate stress
- C. Encouraging the client to avoid discussing the birth experience
- D. Referring the client to a mental health professional for counseling
Correct Answer: A
Rationale: Providing emotional support and empathy for the client's experience should be prioritized to address concerns of a postpartum client who experienced a traumatic birth. Emotional support can help the client feel validated and heard, which can be instrumental in starting the healing process. By acknowledging the client's emotions and experiences, the nurse can establish trust and create a safe space for the client to express their feelings. This can also help in building a therapeutic relationship that can positively impact the client's emotional well-being. Providing a supportive environment is essential for addressing breastfeeding difficulties and emotional distress in this situation.
The nurse who uses appropriate therapeutic listening skills will display which BEST behavior?
- A. Presume an understanding of the patient needs.
- B. Read quickly to the message.
- C. Reassure the patient that everything will be fine.
- D. Absorb both the content and the feeling which patient is conveying
Correct Answer: D
Rationale: The nurse who uses appropriate therapeutic listening skills will display the best behavior by absorbing both the content and the feeling which the patient is conveying. In the given scenario, Belle is experiencing a range of symptoms due to her mental health issues, trauma, and past experiences. By actively listening and absorbing both the content (symptoms, concerns) and the feelings (depressed mood, worry, irritability) which Belle is conveying, the nurse can demonstrate empathy, understanding, and validation of Belle's experiences. This type of therapeutic listening helps to build trust, rapport, and a supportive therapeutic relationship between the nurse and the patient, which is crucial for effective communication, assessment, and treatment in mental health care settings.