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 is a central nervous system depressant used to prevent seizures in clients with severe preeclampsia.

🔴 One of the earliest signs of toxicity is the loss of deep tendon reflexes (DTRs), which precedes respiratory depression and cardiac issues.

🔴 Nurses must assess reflexes frequently during infusion to ensure safe serum levels of the drug.

🔴 A respiratory rate of 12–20/min and urinary output >30 mL/hr are considered within acceptable limits, but absent reflexes warrant immediate intervention.

🔴 The nurse should notify the provider and prepare to administer calcium gluconate, the antidote.

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Answer 2

Correct Answers:

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

Rationale :

🟠 Counterpressure during labor involves applying firm, consistent pressure to the lower back or sacrum, especially useful in occiput posterior fetal position.

🟠 Using a tennis ball or fist, this technique helps relieve back labor pain caused by fetal positioning pressing against the maternal spine.

🟠 The pressure must be steady and synchronized with uterine contractions to provide effective comfort.

🟠 It is a nonpharmacological pain relief method that empowers partners to assist during labor.

🟠 Other techniques like acupressure or distraction can complement counterpressure but are not replacements.

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Answer 3

Correct Answers:

Urine output 20 mL/hr

Rationale :

🟢 Urinary output less than 30 mL/hr in a client receiving magnesium sulfate is a serious concern.

🟢 Since the drug is excreted renally, impaired elimination increases the risk of magnesium toxicity.

🟢 The nurse should monitor output hourly and report reduced urine volume to the provider for dose adjustment.

🟢 While a respiratory rate of 16/min is acceptable, low urine output is a red flag requiring prompt action.

🟢 The provider may consider holding the next dose or initiating calcium gluconate if toxicity develops.

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Answer 4

Correct Answers:

Third-degree perineal laceration

Rationale :

🟣 A third-degree perineal laceration extends through the anal sphincter, creating a high risk for wound dehiscence or infection if rectal agents are introduced.

🟣 Suppositories are contraindicated in this context because insertion could traumatize healing tissues.

🟣 The nurse should opt for oral stool softeners, increased fluids, and fiber-rich foods to manage constipation.

🟣 Although constipation is common postpartum, treatment options should be tailored to the client’s perineal integrity.

🟣 Abdominal distention or vaginal conditions do not present the same contraindication as an anal sphincter injury.

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Answer 5

Correct Answers:

The client has a fundal height of 38 cm

Rationale :

🔵 Fundal height at 32 weeks gestation should measure approximately 32 cm, give or take 2 cm.

🔵 A measurement of 38 cm suggests possible macrosomia or polyhydramnios, both of which are complications of gestational diabetes mellitus (GDM).

🔵 This finding may indicate poor glycemic control or fetal overgrowth, necessitating further evaluation.

🔵 Monitoring fetal size via ultrasound and reviewing maternal glucose management should be initiated.

🔵 This is more significant than a normal fasting glucose or fetal movement count.

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Answer 6

Correct Answers:

Midline episiotomy

Rationale :

⚫ A midline episiotomy is a controlled surgical cut to the perineum made during delivery and presents a potential site for infection.

⚫ This wound must be monitored closely, as it can allow bacteria to enter and lead to postpartum complications.

⚫ Other listed conditions such as gestational hypertension or placenta previa do not inherently increase infection risk.

⚫ Nurses should provide perineal care education, monitor for signs of infection, and document wound healing.

⚫ Midline incisions, though quicker to heal, are more likely to extend into the rectal area if not managed well.

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Answer 7

Correct Answers:

Turn the client onto their side

Rationale :

⚪ Epidural anesthesia can cause vasodilation and hypotension, compromising uteroplacental perfusion.

⚪ The first intervention is to turn the client to the side to relieve aortocaval compression and improve blood flow.

⚪ Repositioning enhances venous return and stabilizes maternal and fetal circulation.

⚪ This is more immediate and effective than medication or amnioinfusion in the setting of hypotension.

⚪ Further interventions may include IV fluids or vasopressors if BP remains low.

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Answer 8

Correct Answers:

"l will drink water before the test until my bladder feels full."

Rationale :

🟡 A full bladder during an abdominal ultrasound acts as an acoustic window, lifting the uterus into a better position for imaging.

🟡 The nurse should instruct the client to drink water beforehand and avoid urinating until after the procedure.

🟡 This improves visualization of fetal structures, particularly during early gestation when the uterus is still pelvic.

🟡 Perfumed lotions, food restrictions, or laxatives are not necessary preparations for this test.

🟡 The client demonstrates understanding when they recognize the importance of bladder filling.

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Answer 9

Correct Answers:

Increased urination

Rationale :

🔷 Clients with hyperglycemia often experience polyuria, or increased urination, due to osmotic diuresis from high blood glucose levels.

🔷 As blood glucose rises, the kidneys excrete more glucose in urine, pulling water with it and causing frequent urination.

🔷 Other signs of hyperglycemia include thirst, fatigue, blurred vision, and dry mouth.

🔷 Sweating and dizziness are more associated with hypoglycemia, not hyperglycemia.

🔷 The nurse should monitor trends in blood glucose levels to guide treatment and reduce fetal complications.

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Answer 10

Correct Answers:

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

Rationale :

🔶 A nonstress test (NST) is considered reactive when there are two or more accelerations of at least 15 bpm lasting 15 seconds within 20 minutes.

🔶 In this case, the acceleration was only 10 seconds, which is insufficient to classify the result as reactive.

🔶 A nonreactive result like this necessitates further testing, such as a biophysical profile or contraction stress test.

🔶 Detecting inadequate fetal response early helps prevent fetal distress or compromise.

🔶 A reactive NST reflects adequate oxygenation and neurological function in the fetus.

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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 counterpressure 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 is 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 providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

9 :
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?

10 :
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?

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 counterpressure 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 is 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 providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

9 : 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?

10 : 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?

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 counterpressure 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 is 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 providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

9 :
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?

10 :
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?