Question

A woman who is 37 weeks gestation is diagnosed with pre-eclampsia. She asks the nurse why she is getting Magnesium Sulfate. What is the best response?

Answer 1

Correct Answers:

It decreases the risk of seizures

Rationale :

🔷 Magnesium sulfate is administered in preeclampsia primarily for seizure prophylaxis, not for controlling blood pressure.

🔷 It acts as a central nervous system depressant, helping to prevent the progression to eclampsia.

🔷 Magnesium sulfate does not treat hypertension directly, though its CNS effects may indirectly reduce blood pressure.

🔷 Clinical signs such as headache and blurred vision are signs of worsening preeclampsia; magnesium does not treat these symptoms directly but prevents seizure progression.

🔷 Close monitoring of deep tendon reflexes, respiratory rate, and urinary output is essential due to magnesium’s narrow therapeutic window.

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Answer 2

Correct Answers:

Physiologic jaundice

Rationale :

💎 Physiologic jaundice typically appears after the first 24 hours of life, most often peaking around 48 to 72 hours, making it the likely diagnosis.

💎 It occurs due to the immature liver unable to process bilirubin quickly enough, leading to mild unconjugated hyperbilirubinemia.

💎 Treatment usually includes phototherapy or biliblanket use and increased feedings to promote bilirubin excretion.

💎 It is not usually harmful and resolves without long-term consequences if managed appropriately.

💎 Unlike pathologic jaundice, which appears within the first 24 hours, physiologic jaundice follows a normal postnatal trajectory

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Answer 3

Correct Answers:

Turn the patient to her side.
Provide 2-3 liters of oxygen via mask
Notify the health care provider.
Stop the oxytocin

Rationale :

✅ Turn the patient to her side – This improves uteroplacental blood flow by relieving vena cava compression.

✅ Provide 2–3 liters of oxygen via mask – Oxygenation helps improve fetal status during hypoxia.

✅Notify the health care provider – Late decelerations indicate uteroplacental insufficiency, requiring provider evaluation.

✅ Stop the oxytocin – Discontinuing oxytocin halts uterine hyperstimulation, improving fetal perfusion.

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Answer 4

Correct Answers:

Monitor oxygen saturation.
Begin droplet precautions.
Initiate IV access.

Rationale :

🟢 Monitor oxygen saturation – Continuous monitoring helps detect respiratory distress early, which is a critical concern in epiglottitis.

🟢 Begin droplet precautions – Haemophilus influenzae type B is spread via droplets, necessitating isolation.

🟢 Initiate IV access – Allows for rapid administration of fluids and medications in case of respiratory deterioration.

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Answer 5

Correct Answers:

"This change in hematocrit indicates a postpartum hemorrhage."

Rationale :

🔴 A hematocrit drop from 35% to 25% within 4 hours postpartum is a significant loss that strongly suggests postpartum hemorrhage (PPH).

🔴 This change exceeds the expected normal drop, which might occur due to hemodilution after fluid shifts but not to this extent.

🔴 PPH is defined as a cumulative blood loss of ≥500 mL (vaginal) or ≥1000 mL (cesarean) within 24 hours.

🔴 Hematocrit drops of 10% or more are clinical red flags, particularly when accompanied by other signs like tachycardia, hypotension, or pallor.

🔴 This requires immediate nursing recognition, provider notification, and intervention such as fundal massage or uterotonics.

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Answer 6

Correct Answers:

P 132

Rationale :

🟣 Terbutaline, a beta-adrenergic agonist, can cause maternal tachycardia as a side effect.

🟣 A heart rate over 120 bpm is concerning and considered a relative contraindication to its administration.

🟣 Administering Terbutaline in the presence of tachycardia could further compromise cardiac output and increase maternal risk.

🟣 Close cardiac monitoring is essential with this drug, especially in patients with a history of cardiovascular concerns.

🟣 The nurse should question and clarify the order with the provider before administering Terbutaline.

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Answer 7

Correct Answers:

A pulse of 132 is high and could be a sign of tachycardia, which is a known side effect of Terbutaline, potentially making the use of this medication unsafe.

Rationale :

🟢 This explanation confirms that maternal pulse over 120 is a risk factor when administering Terbutaline.

🟢 Tachycardia increases the chance of arrhythmias and cardiovascular strain, especially in late pregnancy.

🟢 Terbutaline is generally withheld when maternal HR exceeds 120–130 bpm, per protocol or clinical judgment.

🟢 Fetal safety and maternal cardiac stability must both be evaluated before administration.

🟢 Always assess maternal vitals prior to administering beta-agonists in labor scenarios.

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Answer 8

Correct Answers:

Maternal hypotension
The patient did not get an IV bolus prior to the epidural.

Rationale :

🟢 Maternal hypotension – Epidurals cause vasodilation, which can lower maternal blood pressure and reduce uteroplacental perfusion, resulting in late decelerations.

🟢 The patient did not get an IV bolus prior to the epidural – A preload of IV fluids is given before an epidural to prevent hypotension. Without it, the risk of reduced blood flow to the placenta increases, leading to fetal distress.

🟢 Late decelerations are associated with uteroplacental insufficiency and are non-reassuring signs.

🟢 Early identification of maternal factors like hypotension or poor fluid status is essential for prevention.

🟢 Nurse interventions include positioning, fluid bolus, and notifying the provider.

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Answer 9

Correct Answers:

Category 1 tracing

Rationale :

🔴 A Category 1 fetal heart tracing includes baseline 110–160 bpm, moderate variability, no late or variable decelerations, and may include early decelerations or accelerations.

🔴 A FHR of 155 bpm with moderate variability, and early decelerations is reassuring and falls under Category 1.

🔴 Early decelerations mirror contractions and indicate fetal head compression, a benign finding during labor.

🔴 No signs of hypoxia or acidosis are present in a Category 1 tracing.

🔴 Such findings warrant continued routine monitoring rather than intervention.

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Answer 10

Correct Answers:

HIV
Urine glucose
Rubella Titer
Toxoplasmosis screen

Rationale :

🟣 HIV – Due to the high-risk sexual history, HIV screening is critical to prevent vertical transmission.

🟣 Rubella Titer – Needed to assess immunity status, as rubella infection in pregnancy can lead to severe fetal defects.

🟣 Toxoplasmosis screen – Exposure to cats (especially litter) increases risk of toxoplasmosis, which can cause neurodevelopmental damage to the fetus.

🟣 Vaginal cultures for STDs – Due to multiple sexual partners, she’s at increased risk for gonorrhea, chlamydia, and bacterial vaginosis, which impact pregnancy outcomes.

🟣 These labs are vital during the first prenatal visit to identify and mitigate infectious risks early.

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QLexNursing

1 :
A woman who is 37 weeks gestation is diagnosed with pre-eclampsia. She asks the nurse why she is getting Magnesium Sulfate. What is the best response?

2 :
A newborn is diagnosed with jaundice at 48 hours when the nurse is doing the discharge teaching. The newborn is treated with a biliblanket and frequent feedings. What type of jaundice did the newborn probably have?

3 :
When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply

4 :
A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply

5 :
A patient had a vaginal birth 4 hours ago. Her hematocrit of 35% on admission for labor. Her current hematocrit is 25% which of the following statements by the nurse might best explain that

6 :
The doctor writes an order for Terbutaline to be given 5Q. Which assessment finding will cause the nurse to question this order?

7 :
A blood pressure of 94/60 is low but not typically a contraindication for Terbutaline administration

8 :
Your patient received an epidural approximately 30 minutes ago. You notice late decelerations while evaluating the FHR tracing, Which of the following might be reasons that late decelerations occurring? (Select all that apply).

9 :
The nurse is assessing a fetal heart rate tracing and notices a FHR of 155 bpm with moderate variability, accelerations, and early decelerations. The nurse will chart this a?

QLexNursing

1 : A woman who is 37 weeks gestation is diagnosed with pre-eclampsia. She asks the nurse why she is getting Magnesium Sulfate. What is the best response?

2 : A newborn is diagnosed with jaundice at 48 hours when the nurse is doing the discharge teaching. The newborn is treated with a biliblanket and frequent feedings. What type of jaundice did the newborn probably have?

3 : When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply

4 : A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply

5 : A patient had a vaginal birth 4 hours ago. Her hematocrit of 35% on admission for labor. Her current hematocrit is 25% which of the following statements by the nurse might best explain that

6 : The doctor writes an order for Terbutaline to be given 5Q. Which assessment finding will cause the nurse to question this order?

7 : A blood pressure of 94/60 is low but not typically a contraindication for Terbutaline administration

8 : Your patient received an epidural approximately 30 minutes ago. You notice late decelerations while evaluating the FHR tracing, Which of the following might be reasons that late decelerations occurring? (Select all that apply).

9 : The nurse is assessing a fetal heart rate tracing and notices a FHR of 155 bpm with moderate variability, accelerations, and early decelerations. The nurse will chart this a?

1 :
A woman who is 37 weeks gestation is diagnosed with pre-eclampsia. She asks the nurse why she is getting Magnesium Sulfate. What is the best response?

2 :
A newborn is diagnosed with jaundice at 48 hours when the nurse is doing the discharge teaching. The newborn is treated with a biliblanket and frequent feedings. What type of jaundice did the newborn probably have?

3 :
When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply

4 :
A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply

5 :
A patient had a vaginal birth 4 hours ago. Her hematocrit of 35% on admission for labor. Her current hematocrit is 25% which of the following statements by the nurse might best explain that

6 :
The doctor writes an order for Terbutaline to be given 5Q. Which assessment finding will cause the nurse to question this order?

7 :
A blood pressure of 94/60 is low but not typically a contraindication for Terbutaline administration

8 :
Your patient received an epidural approximately 30 minutes ago. You notice late decelerations while evaluating the FHR tracing, Which of the following might be reasons that late decelerations occurring? (Select all that apply).

9 :
The nurse is assessing a fetal heart rate tracing and notices a FHR of 155 bpm with moderate variability, accelerations, and early decelerations. The nurse will chart this a?