Question

A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

Answer 1

Correct Answers:

Absent deep tendon reflexes

Rationale :

🧠 Magnesium sulfate toxicity depresses neuromuscular transmission, with absent or diminished DTRs being a critical early sign.

🧠 Normal signs of magnesium effect include reduced contraction frequency, slight drowsiness, and mild flushing.

🧠 Urine output of ≥30 mL/hr is acceptable, but DTR absence signals possible progression to respiratory paralysis.

🧠 Always monitor DTRs, respiratory rate, and urine output to ensure safe serum levels.

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Answer 2

Correct Answers:

"Your partner will apply steady pressure with a tennis ball to your lower back."

Rationale :

🎾 Counter-pressure relieves back labor pain, especially when the fetus is in occiput posterior position.

🎾 Using a tennis ball or fist to apply firm, steady pressure to the sacral area helps reduce discomfort.

🎾 This technique allows partners to actively support during contractions.

🎾 Pressure should be adjusted based on maternal feedback and comfort.

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Answer 3

Correct Answers:

Urine output 20 mL/hr

Rationale :

💧 Oliguria (<30 mL/hr) is a sign of magnesium toxicity and renal insufficiency, as magnesium is excreted via kidneys.

💧 Continued magnesium administration in this setting could lead to toxic accumulation and respiratory depression.

💧 Regular monitoring of urine output, respiratory rate, and reflexes is essential.

💧 Report immediately if output falls below 30 mL/hr.

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Answer 4

Correct Answers:

Third-degree perineal laceration

Rationale :

🚫 A third-degree laceration involves the anal sphincter, and using a suppository can cause wound dehiscence or pain.

🚫 This contraindicates rectal interventions in the early postpartum period.

🚫 Use oral stool softeners instead to prevent constipation and protect healing tissues.

🚫 Vaginal candidiasis, distention, and afterpains are not direct contraindications.

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Answer 5

Correct Answers:

The client has a fundal height of 38 cm

Rationale :

📏 At 32 weeks, a fundal height of 38 cm suggests excessive uterine growth, possibly from polyhydramnios or macrosomia.

📏 These are complications often seen in gestational diabetes due to excess fetal glucose and insulin.

📏 Further evaluation with ultrasound and glucose management is required.

📏 The other findings are within expected limits.

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Answer 6

Correct Answers:

Midline episiotomy

Rationale :

🩹 A midline episiotomy creates a perineal wound, increasing the risk of postpartum infection if not properly cared for.

🩹 Good hygiene, monitoring for redness/swelling, and perineal care are essential to prevent wound infection.

🩹 Other listed conditions do not directly increase infection risk postpartum.

🩹 Nursing care should emphasize hand hygiene and pericare.

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Answer 7

Correct Answers:

Turn the client onto their side

Rationale :

🔄 Epidural anesthesia can cause hypotension due to vasodilation and decreased venous return.

🔄 Lateral positioning relieves vena cava compression and improves maternal and placental perfusion.

🔄 BP should be rechecked frequently, and IV fluids and oxygen may be used if symptoms persist.

🔄 Naloxone is used for opioid overdose, not epidural-induced hypotension.

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Answer 8

Correct Answers:

Increased urination

Rationale :

🍬 Polyuria is a classic symptom of hyperglycemia due to osmotic diuresis from excess glucose.

🍬 Other signs include thirst, dry mouth, blurred vision, and fatigue.

🍬 Sweating and dizziness are signs of hypoglycemia, not hyperglycemia.

🍬 Monitoring glucose and urine output helps detect fluctuations in diabetic pregnancy.

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Answer 9

Correct Answers:

An increase in foetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to foetal movement within a 40- min testing period

Rationale :

📊 For a reactive NST, FHR accelerations should be at least 15 bpm above baseline for 15 seconds, twice in 20 mins.

📊 This example does not meet the criteria (only 10 seconds), so further testing is warranted.

📊 This may indicate fetal compromise or sleep cycle, requiring BPP or CST.

📊 NST interpretation is vital in late pregnancy monitoring.

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Answer 10

Correct Answers:

Administer broad-spectrum antibiotics

Rationale :

🧪 A leaking myelomeningocele exposes the spinal cord to infection risk, making broad-spectrum antibiotics critical.

🧪 Avoid rectal temps or iodine cleansing—sterile, protective care only.

🧪 Early neurosurgical intervention may follow once stabilized.

🧪 Antibiotics help prevent meningitis and sepsis in this high-risk scenario.

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QLexNursing

1 :
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

2 :
A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?

3 :
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

4 :
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

5 :
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

6 :
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?

7 :
A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?

9 :
A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

10 :
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

QLexNursing

1 : A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

2 : A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?

3 : A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

4 : A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

5 : A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

6 : A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?

7 : A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

8 : A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?

9 : A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

10 : A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

1 :
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

2 :
A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?

3 :
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

4 :
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

5 :
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

6 :
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?

7 :
A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?

9 :
A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

10 :
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?