Question

A nurse is caring for a client who is on IV magnesium sulfate 12 hours postpartum. The client had a vaginal birth following induction of labor at 35 weeks due to preeclampsia. Which of the following should the nurse recognize as an adverse effect of this treatment?

Answer 1

Correct Answers:

Uterine atony with fundal massage

Rationale :

🔴 Magnesium sulfate acts as a smooth muscle relaxant, which can decrease uterine tone and contribute to uterine atony, a serious postpartum complication.

🔴 Uterine atony increases risk for postpartum hemorrhage, and this is a recognized adverse effect because magnesium can interfere with effective uterine contraction after birth.

🔴 A “boggy” uterus that requires repeated fundal massage is an important warning sign that the uterus is not maintaining adequate tone.

🔴 In a postpartum client receiving magnesium sulfate, decreased uterine tone is more concerning than common expected effects such as warmth or normal urine output.

🔴 Because uterine atony can rapidly lead to excessive bleeding, it is the adverse effect the nurse should recognize and address promptly.

❌ Report of uterine afterpains of 8 on a scale of 0 to 10

❌ Afterpains are common postpartum uterine cramping and can occur normally as the uterus involutes, especially after labor stimulation.

❌ Pain alone does not indicate a magnesium sulfate adverse effect in the way loss of uterine tone does.

❌ Report of warmth at IV site

❌ A sensation of warmth or flushing can occur with magnesium sulfate and may be an expected effect rather than a dangerous adverse reaction.

❌ This does not represent the same level of clinical concern as uterine atony.

❌ Urine output of 50 mL/hr

❌ Urine output of 50 mL/hr is generally adequate and does not indicate magnesium toxicity.

❌ Concern for magnesium accumulation would increase if urine output were significantly reduced, often less than 30 mL/hr.

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Answer 2

Correct Answers:

0.5

Rationale :

Ordered dose: 250 mg

Available dose: 500 mg per tablet

Formula:

Tablets to give = Ordered dose ÷ Available dose

Work:

Tablets to give = 250 mg ÷ 500 mg

Tablets to give = 0.5

✅ Answer: 0.5 tablet

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Answer 3

Correct Answers:

Assess the client's support system.

Rationale :

🔷 Assessment is the priority first action because the nursing process begins with collecting data before implementing interventions or requesting treatments.

🔷 Evaluating the client’s support system helps identify emotional resources, safety concerns, coping ability, and risk for worsening depression during pregnancy.

🔷 A strong or weak support network can significantly influence adherence, stress levels, and need for further mental health intervention.

🔷 The nurse should assess before suggesting alternative treatments, obtaining referrals, or anticipating medication therapy.

🔷 Because this question asks what the nurse should do first, assessment of support systems is the correct priority.

❌ Assist the client with alternative treatments

❌ Alternative treatments may be considered later, but initiating interventions before adequate assessment is premature.

❌ The nurse first needs data about psychosocial supports and current mental health status.

❌ Request a prescription for fluoxetine

❌ Medication decisions require provider evaluation and should not precede nursing assessment.

❌ The stem does not indicate an immediate need to request pharmacologic treatment first.

❌ Obtain a referral for a mental health provider

❌ Referral may be appropriate, but the nurse should first assess the client’s current support system and needs.

❌ Assessment guides whether referral urgency or additional interventions are needed.

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Answer 4

Correct Answers:

Administer oxygen therapy.

Rationale :

💎 Grunting, retractions, nasal flaring, and tachypnea are classic signs of respiratory distress in a newborn.

💎 The immediate priority is to improve oxygenation, making oxygen therapy the most appropriate intervention.

💎 A heart rate of 174/min is elevated but does not indicate the need for chest compressions, which are reserved for severe bradycardia.

💎 Early oxygen support may reduce worsening respiratory compromise while additional neonatal evaluation occurs.

💎 Because airway and breathing take priority, administering oxygen is the correct immediate action.

❌ Give the newborn epinephrine

❌ Epinephrine is used in neonatal resuscitation for severe cardiac compromise, not routine respiratory distress.

❌ This newborn’s heart rate does not support that intervention.

❌ Place the newborn in a prone position

❌ Prone positioning is not the priority intervention for acute respiratory distress immediately after birth.

❌ Oxygen support addresses the urgent physiologic problem more directly.

❌ Initiate chest compressions

❌ Chest compressions are indicated when the newborn heart rate remains below 60/min despite ventilation.

❌ A heart rate of 174/min does not support compressions.

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Answer 5

Correct Answers:

Temperature instability
Jitteriness
Hypotonia

Rationale :

✅ Temperature instability

🔶 Temperature instability is a recognized sign of neonatal hypoglycemia because low glucose can impair normal metabolic heat production.

🔶 Newborns with inadequate glucose stores may have difficulty maintaining body temperature and may become cold or unstable.

🔶 Hypothermia can also increase glucose consumption, worsening hypoglycemia further.

🔶 This is why temperature instability should prompt evaluation of blood glucose in a newborn.

🔶 It is an important early clinical sign that should not be overlooked.

✅ Jitteriness

🔶 Jitteriness is a classic sign of low blood glucose in newborns and often reflects neurologic irritability.

🔶 Inadequate glucose supply affects the brain, which can lead to tremors, shakiness, or jittery movements.

🔶 This finding is frequently tested as a hallmark symptom of neonatal hypoglycemia.

🔶 Persistent jitteriness warrants prompt glucose assessment and intervention.

🔶 It is one of the most common early manifestations of this condition.

✅ Hypotonia

🔶 Hypotonia may occur when insufficient glucose affects neuromuscular and neurologic function.

🔶 A hypoglycemic newborn may appear weak, floppy, lethargic, or have poor muscle tone.

🔶 This reflects inadequate energy supply to support normal newborn activity.

🔶 Because hypotonia may indicate worsening compromise, it is a significant assessment finding.

🔶 It is consistent with neonatal hypoglycemia and should be recognized promptly.

❌ Abdominal distention

❌ Abdominal distention is not a classic sign of neonatal hypoglycemia.

❌ It may point toward gastrointestinal or other neonatal concerns rather than low glucose.

❌ Acrocyanosis

❌ Acrocyanosis is a common normal newborn finding involving bluish hands and feet in early transition.

❌ It is not considered an indicator of hypoglycemia.

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Answer 6

Correct Answers:

Exaggerated Moro reflex
Tachypnea

Rationale :

✅ Exaggerated Moro reflex

🟣 Neonatal abstinence syndrome (NAS) often causes central nervous system irritability, leading to an exaggerated Moro reflex.

🟣 Newborns experiencing withdrawal may startle excessively and have increased reflex responses.

🟣 Hyperirritability is a common hallmark of NAS.

🟣 This finding reflects overstimulation of the nervous system during withdrawal.

🟣 It is a classic expected manifestation.

✅ Tachypnea

🟣 Tachypnea is also commonly seen in newborns with NAS due to autonomic nervous system overactivity.

🟣 Withdrawal may produce increased respiratory rate along with sneezing, yawning, and irritability.

🟣 Rapid breathing is an expected physiologic response associated with neonatal withdrawal.

🟣 Respiratory status requires monitoring because severe symptoms may affect feeding and stability.

🟣 This makes tachypnea an expected finding.

❌ Hypotonia

❌ Newborns with NAS more commonly show hypertonia, increased tone, and irritability rather than decreased tone.

❌ Hypotonia is not a classic expected withdrawal finding.

❌ Acrocyanosis

❌ Acrocyanosis may be a normal transitional newborn finding and is not a defining manifestation of NAS.

❌ It does not specifically indicate neonatal withdrawal.

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Answer 7

Correct Answers:

Blood pressure 80/55 mm Hg

Rationale :

🔴 Hypotension with a blood pressure of 80/55 mm Hg is a significant sign of fluid volume deficit and possible hypovolemia after postpartum blood loss.

🔴 A quantified blood loss of 1200 mL after cesarean birth is concerning for postpartum hemorrhage risk, making circulatory status a priority.

🔴 Low blood pressure may indicate decreased intravascular volume and inadequate tissue perfusion, both classic findings in volume depletion.

🔴 In postpartum clients, hypotension following major blood loss is more concerning than mild temperature elevation or sweating.

🔴 Because it signals possible hemodynamic instability, this finding most strongly indicates fluid volume deficit.

❌ Temperature 37.6°C (99.6°F)

❌ A temperature of 37.6°C is only mildly elevated and does not indicate fluid volume deficit.

❌ It is not as significant as hypotension when assessing for hypovolemia.

❌ Reports of excessive sweating

❌ Sweating alone is nonspecific and does not confirm fluid volume deficit.

❌ It does not provide the same direct evidence of circulatory compromise as hypotension.

❌ 900 mL of urine output since the birth

❌ 900 mL urine output suggests adequate renal perfusion and does not support volume depletion.

❌ In fluid deficit, reduced urine output would be more concerning than abundant output.

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Answer 8

Correct Answers:

Heart palpitations

Rationale :

💎 Terbutaline is a beta-adrenergic agonist that can stimulate the cardiovascular system and cause tachycardia and palpitations.

💎 Heart palpitations are a recognized adverse effect because terbutaline may increase maternal heart rate and cause a sensation of pounding or racing heartbeat.

💎 This effect is important to monitor because excessive cardiovascular stimulation may indicate intolerance or toxicity.

💎 While terbutaline relaxes uterine smooth muscle, it can also affect beta receptors outside the uterus, producing cardiac side effects.

💎 Among the options, palpitations are the most classic and expected adverse effect.

❌ Hot flashes

❌ Hot flashes are not a classic priority adverse effect associated with terbutaline therapy.

❌ Cardiovascular stimulation such as palpitations is more characteristic of this medication.

❌ Shortness of breath

❌ Shortness of breath is concerning, but it is not the classic expected adverse effect being tested here.

❌ The more commonly tested maternal adverse effect is tachycardia/palpitations.

❌ Bradycardia

❌ Bradycardia is the opposite of what is expected with terbutaline.

❌ This medication is associated with tachycardia, not slowed heart rate.

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Answer 9

Correct Answers:

Discontinue the oxytocin IV infusion.

Rationale :

🔷 Six contractions in 10 minutes indicates uterine tachysystole, and when paired with a non-reassuring fetal heart rate (FHR) tracing, the immediate priority is to remove the cause of excessive uterine stimulation.

🔷 Oxytocin can reduce uteroplacental perfusion when contractions become too frequent, placing the fetus at risk for hypoxia.

🔷 The first action is to stop the oxytocin infusion to reduce uterine overstimulation and improve fetal oxygenation.

🔷 Repositioning and oxygen may also be appropriate interventions, but they occur after removing the precipitating cause.

🔷 Because the question asks what to do first, discontinuing oxytocin is the priority action.

❌ Turn the client to their left side

❌ Left lateral positioning may improve uteroplacental blood flow and is an appropriate supportive intervention.

❌ However, the first priority is to stop the medication causing the tachysystole.

❌ Administer terbutaline 0.25 mg subcutaneously

❌ Terbutaline may be used if tachysystole persists, but it is not the first step.

❌ The nurse should first discontinue the oxytocin before escalating to tocolytic treatment.

❌ Apply oxygen at 10 L/min via face mask

❌ Oxygen may be supportive in intrauterine resuscitation, but it does not remove the cause of uterine overstimulation.

❌ Priority is stopping the oxytocin infusion first.

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Answer 10

Correct Answers:

"l should empty my bladder before the procedure."

Rationale :

💎 At 35 weeks gestation, the client should empty the bladder before amniocentesis to reduce risk of bladder puncture and improve safety during the procedure.

💎 In later pregnancy, unlike earlier gestation when a full bladder may sometimes be helpful, a voided bladder is typically preferred.

💎 This statement demonstrates correct understanding of preparation for a third-trimester amniocentesis.

💎 The procedure is generally performed with the client awake using ultrasound guidance, and routine prolonged fasting is not required.

💎 Because this statement accurately reflects appropriate preparation, it is the correct answer.

❌ "I will be asleep during the procedure."

❌ Clients are generally awake, not under general anesthesia, during amniocentesis.

❌ This statement reflects misunderstanding of the procedure.

❌ "I will be lying on my side during the procedure."

❌ The client is generally positioned supine, not side-lying, for the procedure.

❌ This does not reflect correct teaching.

❌ "I should start fasting 24 hours before the procedure."

❌ Routine 24-hour fasting is not standard preparation for amniocentesis.

❌ This statement indicates incorrect understanding.

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QLexNursing

1 :
A nurse is caring for a client who is on IV magnesium sulfate 12 hours postpartum. The client had a vaginal birth following induction of labor at 35 weeks due to preeclampsia. Which of the following should the nurse recognize as an adverse effect of this treatment?

3 :
A nurse is planning care for a client who is at 10 weeks of gestation and has a history of depression. Which of the following actions should the nurse take first?

4 :
A nurse is caring for a newborn immediately following birth who is grunting and retracting, and has nasal flaring, a respiratory rate of 72/min, and a heart rate of 174/min. Which of the following actions should the nurse take?

5 :
A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

6 :
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect? (Select all that apply.)

7 :
A nurse is caring for a client who is 9 hours postpartum following a cesarean birth with a quantitative blood loss of 1200 mL. Which of the following findings indicates the client is experiencing a fluid volume deficit?

8 :
A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

9 :
A nurse is assessing a client who is receiving oxytocin via continuous IV infusion for labor augmentation. The nurse notes six contractions in a 10- min period with a non-reassuring FHR tracing. Which of the following actions should the nurse take first?

10 :
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?

QLexNursing

1 : A nurse is caring for a client who is on IV magnesium sulfate 12 hours postpartum. The client had a vaginal birth following induction of labor at 35 weeks due to preeclampsia. Which of the following should the nurse recognize as an adverse effect of this treatment?

3 : A nurse is planning care for a client who is at 10 weeks of gestation and has a history of depression. Which of the following actions should the nurse take first?

4 : A nurse is caring for a newborn immediately following birth who is grunting and retracting, and has nasal flaring, a respiratory rate of 72/min, and a heart rate of 174/min. Which of the following actions should the nurse take?

5 : A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

6 : A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect? (Select all that apply.)

7 : A nurse is caring for a client who is 9 hours postpartum following a cesarean birth with a quantitative blood loss of 1200 mL. Which of the following findings indicates the client is experiencing a fluid volume deficit?

8 : A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

9 : A nurse is assessing a client who is receiving oxytocin via continuous IV infusion for labor augmentation. The nurse notes six contractions in a 10- min period with a non-reassuring FHR tracing. Which of the following actions should the nurse take first?

10 : A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?

1 :
A nurse is caring for a client who is on IV magnesium sulfate 12 hours postpartum. The client had a vaginal birth following induction of labor at 35 weeks due to preeclampsia. Which of the following should the nurse recognize as an adverse effect of this treatment?

3 :
A nurse is planning care for a client who is at 10 weeks of gestation and has a history of depression. Which of the following actions should the nurse take first?

4 :
A nurse is caring for a newborn immediately following birth who is grunting and retracting, and has nasal flaring, a respiratory rate of 72/min, and a heart rate of 174/min. Which of the following actions should the nurse take?

5 :
A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

6 :
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect? (Select all that apply.)

7 :
A nurse is caring for a client who is 9 hours postpartum following a cesarean birth with a quantitative blood loss of 1200 mL. Which of the following findings indicates the client is experiencing a fluid volume deficit?

8 :
A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

9 :
A nurse is assessing a client who is receiving oxytocin via continuous IV infusion for labor augmentation. The nurse notes six contractions in a 10- min period with a non-reassuring FHR tracing. Which of the following actions should the nurse take first?

10 :
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?