Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Respiratory rate
Respiratory rate is the priority nursing assessment for this client, because magnesium sulfate can cause respiratory depression, which is a life-threatening complication. The nurse should monitor the client's respiratory rate closely, and discontinue the infusion if it falls below 12 breaths per minute.
B. Bowel sounds
Bowel sounds is not a priority nursing assessment for this client, because magnesium sulfate does not have a significant effect on the gastrointestinal system. The nurse should assess the client's bowel sounds as part of the routine physical examination, but it is not a critical parameter for this medication.
C. Time of last food intake
Time of last food intake is not a priority nursing assessment for this client, because magnesium sulfate does not interact with food or affect the absorption of nutrients. The nurse should inquire about the client's dietary intake and preferences, but it is not a vital factor for this medication.
D. Temperature
Temperature is not a priority nursing assessment for this client, because magnesium sulfate does not cause fever or hypothermia. The nurse should measure the client's temperature as part of the vital signs, but it is not a key indicator for this medication.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam 4. Take the full exam now
Full Explanation
Choice A reason: Respiratory rate is the priority nursing assessment for this client, because magnesium sulfate can cause respiratory depression, which is a life-threatening complication. The nurse should monitor the client's respiratory rate closely, and discontinue the infusion if it falls below 12 breaths per minute.
Choice B reason: Bowel sounds is not a priority nursing assessment for this client, because magnesium sulfate does not have a significant effect on the gastrointestinal system. The nurse should assess the client's bowel sounds as part of the routine physical examination, but it is not a critical parameter for this medication.
Choice C reason: Time of last food intake is not a priority nursing assessment for this client, because magnesium sulfate does not interact with food or affect the absorption of nutrients. The nurse should inquire about the client's dietary intake and preferences, but it is not a vital factor for this medication.
Choice D reason: Temperature is not a priority nursing assessment for this client, because magnesium sulfate does not cause fever or hypothermia. The nurse should measure the client's temperature as part of the vital signs, but it is not a key indicator for this medication.
Similar Questions
A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?
A. Uterine enlargement greater than expected for gestational age
Uterine enlargement greater than expected for gestational age is not a typical manifestation of ectopic pregnancy, because the embryo is implanted outside the uterus, usually in the fallopian tube. The uterus may be slightly enlarged due to hormonal changes, but not more than expected for the gestational age.
B. Unilateral, cramp-like abdominal pain
Unilateral, cramp-like abdominal pain is a common manifestation of ectopic pregnancy, because the embryo grows and stretches the fallopian tube, causing inflammation and irritation. The pain may be mild or severe, depending on the size and location of the ectopic pregnancy, and may radiate to the shoulder or back.
C. Severe nausea and vomiting
Severe nausea and vomiting is not a specific manifestation of ectopic pregnancy, because it can be caused by other conditions, such as hyperemesis gravidarum, gastroenteritis, or appendicitis. The client may have mild nausea and vomiting due to hormonal changes, but not more than usual for the gestational age.
D. Large amount of vaginal bleeding
Large amount of vaginal bleeding is not a usual manifestation of ectopic pregnancy, because the bleeding is usually internal, into the abdominal cavity. The client may have spotting or light bleeding due to the detachment of the endometrium, but not heavy or profuse bleeding.
Full Explanation
Choice A reason: Uterine enlargement greater than expected for gestational age is not a typical manifestation of ectopic pregnancy, because the embryo is implanted outside the uterus, usually in the fallopian tube. The uterus may be slightly enlarged due to hormonal changes, but not more than expected for the gestational age.
Choice B reason: Unilateral, cramp-like abdominal pain is a common manifestation of ectopic pregnancy, because the embryo grows and stretches the fallopian tube, causing inflammation and irritation. The pain may be mild or severe, depending on the size and location of the ectopic pregnancy, and may radiate to the shoulder or back.
Choice C reason: Severe nausea and vomiting is not a specific manifestation of ectopic pregnancy, because it can be caused by other conditions, such as hyperemesis gravidarum, gastroenteritis, or appendicitis. The client may have mild nausea and vomiting due to hormonal changes, but not more than usual for the gestational age.
Choice D reason: Large amount of vaginal bleeding is not a usual manifestation of ectopic pregnancy, because the bleeding is usually internal, into the abdominal cavity. The client may have spotting or light bleeding due to the detachment of the endometrium, but not heavy or profuse bleeding.
A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates an order by the provider for which of the following medications?
A. Prostaglandin E2
Prostaglandin E2 is not an appropriate medication for the client, because it is a uterotonic agent that stimulates uterine contractions and cervical ripening. Prostaglandin E2 is used to induce labor, not to stop it.
B. Methylergonovine
Methylergonovine is not an appropriate medication for the client, because it is a uterotonic agent that causes sustained uterine contractions and vasoconstriction. Methylergonovine is used to prevent or treat postpartum hemorrhage, not to stop preterm labor.
C. Terbutaline
Terbutaline is an appropriate medication for the client, because it is a tocolytic agent that relaxes the uterine smooth muscle and inhibits contractions. Terbutaline is used to delay preterm labor and prolong pregnancy.
D. Oxytocin
Oxytocin is not an appropriate medication for the client, because it is a uterotonic agent that stimulates uterine contractions and milk ejection. Oxytocin is used to augment labor, not to stop it.
Full Explanation
Choice A reason: Prostaglandin E2 is not an appropriate medication for the client, because it is a uterotonic agent that stimulates uterine contractions and cervical ripening. Prostaglandin E2 is used to induce labor, not to stop it.
Choice B reason: Methylergonovine is not an appropriate medication for the client, because it is a uterotonic agent that causes sustained uterine contractions and vasoconstriction. Methylergonovine is used to prevent or treat postpartum hemorrhage, not to stop preterm labor.
Choice C reason: Terbutaline is an appropriate medication for the client, because it is a tocolytic agent that relaxes the uterine smooth muscle and inhibits contractions. Terbutaline is used to delay preterm labor and prolong pregnancy.
Choice D reason: Oxytocin is not an appropriate medication for the client, because it is a uterotonic agent that stimulates uterine contractions and milk ejection. Oxytocin is used to augment labor, not to stop it.
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
A. A client who is experiencing preterm labor at 26 weeks of gestation
A client who is experiencing preterm labor at 26 weeks of gestation is a suitable candidate for tocolytic therapy, because it can help delay the delivery and allow time for fetal lung maturation and transfer to a tertiary care center. Tocolytic therapy is indicated for clients who have regular uterine contractions and cervical changes before 37 weeks of gestation.
B. A client who is experiencing fetal death at 32 weeks of gestation
A client who is experiencing fetal death at 32 weeks of gestation is not a suitable candidate for tocolytic therapy, because it has no benefit for the mother or the fetus. Tocolytic therapy is contraindicated for clients who have fetal demise, as it can increase the risk of infection and coagulation disorders.
C. A client who has a post-term pregnancy at 42 weeks of gestation
A client who has a post-term pregnancy at 42 weeks of gestation is not a suitable candidate for tocolytic therapy, because it can harm the mother and the fetus. Tocolytic therapy is contraindicated for clients who have post-term pregnancy, as it can increase the risk of placental insufficiency, fetal distress, and meconium aspiration.
D. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation is not a suitable candidate for tocolytic therapy, because it is not necessary or effective. Braxton-Hicks contractions are irregular and painless contractions that do not cause cervical changes or labor. They are normal and harmless, and do not require any intervention.
Full Explanation
Choice A reason: A client who is experiencing preterm labor at 26 weeks of gestation is a suitable candidate for tocolytic therapy, because it can help delay the delivery and allow time for fetal lung maturation and transfer to a tertiary care center. Tocolytic therapy is indicated for clients who have regular uterine contractions and cervical changes before 37 weeks of gestation.
Choice B reason: A client who is experiencing fetal death at 32 weeks of gestation is not a suitable candidate for tocolytic therapy, because it has no benefit for the mother or the fetus. Tocolytic therapy is contraindicated for clients who have fetal demise, as it can increase the risk of infection and coagulation disorders.
Choice C reason: A client who has a post-term pregnancy at 42 weeks of gestation is not a suitable candidate for tocolytic therapy, because it can harm the mother and the fetus. Tocolytic therapy is contraindicated for clients who have post-term pregnancy, as it can increase the risk of placental insufficiency, fetal distress, and meconium aspiration.
Choice D reason: A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation is not a suitable candidate for tocolytic therapy, because it is not necessary or effective. Braxton-Hicks contractions are irregular and painless contractions that do not cause cervical changes or labor. They are normal and harmless, and do not require any intervention.