Question

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Answer 1

Correct Answers:

Respiratory depression

Rationale :

🔸 Respiratory depression is a critical sign of magnesium sulfate toxicity and requires immediate notification of the provider.

🔸 Magnesium acts as a central nervous system depressant; in excessive amounts, it can suppress respiratory muscles and reduce respiratory rate below 12 breaths/min.

🔸 Other signs of toxicity include absent deep tendon reflexes, hypotension, and lethargy, but respiratory compromise is the most urgent.

🔸 Therapeutic serum magnesium levels range between 4–7 mEq/L for seizure prophylaxis, but toxicity typically occurs when levels exceed 7.5–10 mEq/L.

🔸 The antidote for magnesium toxicity is calcium gluconate, which should always be readily available when infusing magnesium.

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Answer 2

Correct Answers

Hematocrit level [ Placenta Previa ; Abruptio Placenta ]
Client's pain level [ Placenta Previa ]
Fundal height [ Placenta Previa ; Abruptio Placenta ]
Uterine tone [ Placenta Previa ]
Description of vaginal bleeding [ Placenta Previa ]

Rationale :

Hematocrit level – Consistent with Both Placenta Previa and Abruptio Placenta

❖ A hematocrit of 30% (below the normal threshold of 33% in pregnancy) indicates maternal blood loss.

❖ In placenta previa, blood loss is typically external and visible, causing gradual reductions in hematocrit.

❖ In abruptio placentae, bleeding can be concealed or external, and significant internal bleeding can lower hematocrit quickly.

❖ Therefore, a decreased hematocrit can reflect hemorrhagic complications in both conditions.

❖ It is important to monitor for signs of hypovolemia and initiate fluid replacement promptly in either case.

Client's Pain Level – Consistent with Placenta Previa

❖ The client reports no abdominal pain, which is classic for placenta previa.

❖ Placenta previa typically causes painless, bright red vaginal bleeding due to the placenta being located near or over the cervical os.

❖ In contrast, abruptio placentae often presents with sudden, severe abdominal pain due to premature placental separation.

❖ Absence of pain in this client makes placenta previa more likely than abruption.

❖ Pain assessment helps differentiate the underlying cause of bleeding during the third trimester.

Fundal Height – Consistent with Both Placenta Previa and Abruptio Placenta

❖ The fundal height is 37 cm at 34 weeks gestation, which is larger than expected.

❖ An increased fundal height can result from concealed bleeding (seen in abruptio placentae), or placental abnormalities (such as previa).

❖ In abruption, blood accumulates behind the placenta and may cause uterine distention, increasing fundal height.

❖ In previa, repeated bleeding episodes may also cause uterine enlargement or contribute to polyhydramnios, raising fundal height.

❖ Therefore, this finding is non-specific and can occur in both conditions.

Uterine Tone – Consistent with Placenta Previa

❖ The uterus is described as soft and nontender, which is indicative of placenta previa.

❖ In placenta previa, there is no placental separation, so the uterus does not become irritable or firm.

❖ In contrast, abruptio placentae typically presents with a firm, rigid, and tender uterus due to the accumulation of blood in the uterine wall.

❖ Uterine tone is a critical clinical indicator to differentiate between these conditions.

❖ A soft uterus without pain makes abruption less likely in this client.

Description of Vaginal Bleeding – Consistent with Placenta Previa

❖ The client is experiencing bright red vaginal bleeding, which is classic for placenta previa.

❖ In placenta previa, bleeding originates from the placental site near the cervix, leading to fresh, bright red blood.

❖ This bleeding is often painless and recurrent during the third trimester.

❖ In abruptio placentae, bleeding is usually dark red and often accompanied by pain and uterine tenderness.

❖ Therefore, this bleeding pattern strongly supports a diagnosis of placenta previa.

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Answer 3

Correct Answers:

Provide a dark, quiet environment.
Administer magnesium sulfate IV.
Ensure that calcium gluconate is readily available.

Rationale :

Provide a dark, quiet environment

♦️Clients with severe gestational hypertension or preeclampsia are at risk for seizures due to increased CNS stimulation.

♦️A calm, low-stimulus environment helps reduce sensory input that may trigger seizures.

♦️This is a standard seizure precaution in hypertensive disorders of pregnancy.

♦️Nurses must minimize noise, bright lights, and unnecessary interruptions in care.

Administer magnesium sulfate IV

♦️ Magnesium sulfate is the anticonvulsant of choice to prevent eclampsia (seizure activity) in clients with severe gestational hypertension or preeclampsia.

♦️It acts as a CNS depressant, stabilizing nerve membranes.

♦️The nurse should monitor for signs of toxicity, including respiratory depression and decreased reflexes.

♦️Administration requires IV pump regulation and frequent monitoring.

Ensure that calcium gluconate is readily available

♦️ Calcium gluconate is the antidote for magnesium sulfate toxicity.

♦️ It should be available at the bedside in case of complications such as respiratory arrest or loss of deep tendon reflexes.

♦️The nurse must assess for signs of toxicity frequently during therapy.

♦️Having the antidote on hand is a key component of safe medication administration.

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Answer 4

Correct Answers:

Hypertension.

Rationale :

🟣 Hypertension is the most common risk factor for placental abruption due to its ability to damage blood vessels in the placenta, leading to premature separation.

🟣 Chronic or gestational hypertension can cause vasospasm and compromise placental perfusion, increasing the likelihood of bleeding behind the placenta.

🟣 This can result in reduced oxygen and nutrient delivery to the fetus, contributing to fetal distress or demise.

🟣 The risk is especially high in clients with poorly controlled or severe hypertension.

🟣 Nurses must monitor blood pressure regularly and assess for signs of abruption, such as sudden abdominal pain or dark vaginal bleeding.

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Answer 5

Correct Answers

Blank 1 Correct Option: chorioamnionitis
Blank 2 Correct Option: leakage of vaginal fluid

Rationale :

🟢 Chorioamnionitis is an infection of the amniotic sac and is commonly associated with prolonged rupture of membranes exceeding 18 hours.

🟢 This client has had clear leakage for 12 hours, increasing the risk of ascending bacterial infection from the vaginal canal.

🟢 The presence of a temporal headache, although mild, should be monitored as it may indicate the early stages of infection or inflammation.

🟢 Diagnosis is supported by a positive nitrazine test and ferning, which confirms ruptured membranes.

🟢 Nurses must remain vigilant for signs of infection such as maternal fever, uterine tenderness, and foul-smelling discharge.

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Answer 6

Correct Answers:

Changes in the cervix

Rationale :

🔵 Cervical changes, including dilation and effacement, are definitive signs of true labor.

🔵 Unlike false labor, which may involve irregular contractions, true labor leads to measurable cervical progression.

🔵 This physical change occurs due to consistent, rhythmic uterine contractions that promote fetal descent and birth.

🔵 Assessment through sterile vaginal examination reveals these changes and helps determine labor stage.

🔵 Nurses use cervical dilation and effacement measurements to decide appropriate labor interventions.

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Answer 7

Correct Answers:

Lecithin/sphingomyelin (L/S) ratio of 2:1

Rationale :

🟠 A lecithin/sphingomyelin (L/S) ratio of 2:1 indicates fetal lung maturity, which typically occurs around 35 weeks gestation.

🟠 Lecithin increases as the fetal lungs mature, while sphingomyelin remains relatively stable.

🟠 This ratio is part of the amniotic fluid analysis, which helps clinicians decide timing of delivery in high-risk pregnancies.

🟠 This information is especially important before cesarean birth to minimize the risk of neonatal respiratory distress syndrome.

🟠 A mature L/S ratio helps reassure the care team that the baby can breathe effectively post-delivery.

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Answer 8

Correct Answers:

Insulin

Rationale :

🟡 Insulin is the treatment of choice for gestational diabetes that is uncontrolled by diet and exercise.

🟡 Unlike oral hypoglycemics, insulin does not cross the placenta, making it safe and effective for both the mother and fetus.

🟡 Strict glucose control reduces the risk of complications such as macrosomia, preterm birth, and neonatal hypoglycemia.

🟡 The dosage is carefully tailored and often increased during the third trimester due to placental hormones causing insulin resistance.

🟡 Frequent monitoring of blood glucose is essential during insulin therapy to avoid both hypo- and hyperglycemia.

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Answer 9

Correct Answers:

Report of headache.

Rationale :

🔴 A persistent headache is an expected symptom of severe preeclampsia, often resulting from cerebral vasospasm or hypertension.

🔴 It can signal worsening disease and is commonly associated with blurred vision, epigastric pain, and hyperreflexia.

🔴 This symptom reflects CNS involvement and necessitates close monitoring and prompt management to prevent progression to eclampsia.

🔴 Antihypertensive therapy and magnesium sulfate are typically used to manage severe preeclampsia.

🔴 Immediate reporting and assessment of neurological signs can prevent complications such as seizures or stroke.

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Answer 10

Correct Answers:

“The primary consideration is what type of incision was performed this time.”

Rationale :

🔷 The type of uterine incision used during a previous cesarean birth plays a critical role in determining eligibility for a trial of labor after cesarean (TOLAC).

🔷 A low transverse incision is the most favorable for vaginal birth after cesarean (VBAC) due to its reduced risk of uterine rupture.

🔷 Classical (vertical) incisions pose a greater risk and generally contraindicate future vaginal delivery.

🔷 Knowing the uterine incision, not the skin incision, is the deciding factor—not the overall experience of the prior cesarean.

🔷 It is essential to review operative records from the previous cesarean to evaluate candidacy for VBAC.

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Assessment Findings	Placenta Previa	Abruptio Placenta
Hematocrit level
Client's pain level
Fundal height
Uterine tone
Description of vaginal bleeding

Custom: NUR 2463 Exam #2

No.

1 :
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

2 :
A nurse is caring for a client who is at 34 weeks of gestation.

Correct Answers

3 :
A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

4 :
A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

5 :
A nurse is caring for a client who is in labor.

Correct Answers

6 :
A nurse is caring for a client who is a primigravida. at term. and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

7 :
A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

8 :
A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

9 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

10 :
A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, “Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

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Custom: NUR 2463 Exam #2

No.

1 : A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

2 : A nurse is caring for a client who is at 34 weeks of gestation.

Correct Answers

3 : A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

4 : A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

5 : A nurse is caring for a client who is in labor.

Correct Answers

6 : A nurse is caring for a client who is a primigravida. at term. and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

7 : A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

8 : A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

9 : A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

10 : A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, “Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

1 :
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

2 :
A nurse is caring for a client who is at 34 weeks of gestation.

3 :
A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

4 :
A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

5 :
A nurse is caring for a client who is in labor.

6 :
A nurse is caring for a client who is a primigravida. at term. and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

7 :
A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

8 :
A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

9 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

10 :
A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, “Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?