Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A pregnant woman has been receiving a magnesium sulfate infusion for the treatment of severe preeclampsia for 24 hours.
On assessment, the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus.
The patient complains, “I’m so thirsty and warm.” The nurse:
A. Calls for a stat magnesium sulfate level
This is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity. The nurse should act quickly to prevent further complications.
B. Administers oxygen
This is wrong because administering oxygen will not reverse the effects of magnesium toxicity. Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.
C. Discontinues the magnesium sulfate infusion
The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing. Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely. The nurse should stop the infusion immediately and notify the provider.
D. Prepares to administer hydralazine
This is wrong because hydralazine is an antihypertensive medication that lowers blood pressure. The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg). Hydralazine may cause hypotension and fetal distress.
This question is an excerpt from Nurse Dive's nursing test bank - OB Pediatric Cumulative Exam Test 4 V 1 2023 Proctored Exam. Take the full exam now
Full Explanation
The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing.
Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely.
The nurse should stop the infusion immediately and notify the provider.
Choice A is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity.
The nurse should act quickly to prevent further complications.
Choice B is wrong because administering oxygen will not reverse the effects of magnesium toxicity.
Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.
Choice D is wrong because hydralazine is an antihypertensive medication that lowers blood pressure.
The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg).
Hydralazine may cause hypotension and fetal distress.
Similar Questions
A woman is in her seventh month of pregnancy.
She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:
A. This is a normal respiratory change in pregnancy caused by elevated levels of estrogen.
This is a normal respiratory change in pregnancy caused by elevated levels of estrogen. Estrogen increases blood flow and causes the nasal mucosa to swell, leading to congestion and nosebleeds. This condition is called pregnancy rhinitis and affects up to 20% of pregnant women.
B. This is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
Thisis wrong because this is not an abnormal cardiovascular change, and the nosebleeds are not an ominous sign. They are usually harmless and do not affect the pregnancy outcome.
C. The woman is a victim of domestic violence and is being hit in the face by her partner.
This is wrong because there is no evidence that the woman is a victim of domestic violence. This is a serious accusation that should not be made without proper assessment and screening.
D. The woman has been using cocaine intranasally.
This is wrong because there is no indication that the woman has been using cocaine intranasally. Cocaine use can cause nasal damage and bleeding, but it can also have other signs and symptoms such as agitation, euphoria, dilated pupils, increased heart rate and blood pressure, and risk of miscarriage or preterm labor.
Full Explanation
This is a normal respiratory change in pregnancy caused by elevated levels of estrogen. Estrogen increases blood flow and causes the nasal mucosa to swell, leading to congestion and nosebleeds. This condition is called pregnancy rhinitis and affects up to 20% of pregnant women.
Choice B is wrong because this is not an abnormal cardiovascular change, and the nosebleeds are not an ominous sign. They are usually harmless and do not affect the pregnancy outcome.
Choice C is wrong because there is no evidence that the woman is a victim of domestic violence.
This is a serious accusation that should not be made without proper assessment and screening.
Choice D is wrong because there is no indication that the woman has been using cocaine intranasally. Cocaine use can cause nasal damage and bleeding, but it can also have other signs and symptoms such as agitation, euphoria, dilated pupils, increased heart rate and blood pressure, and risk of miscarriage or preterm labor.
Which infant would be more likely to have Rh incompatibility?
A. Infant of an Rh-negative mother and a father who is Rh-positive and homozygous for the Rh factor.
Infant of an Rh-negative mother and a father who is Rh-positive and homozygous for the Rh factor. Rh incompatibility occurs when a woman is Rh-negative and her baby is Rh-positive. This can cause hemolytic disease of the neonate (HDN), a condition where the mother’s antibodies destroy the baby’s red blood cells.
B. Infant who is Rh negative and whose mother is Rh negative.
This is wrong because if both the mother and the baby are Rh-negative, there is no risk of Rh incompatibility.
C. Infant of an Rh-negative mother and a father who is Rh-positive and heterozygous for the Rh factor.
This is wrong because if the father is heterozygous for the Rh factor, there is a 50% chance that the baby will be Rh-negative and not affected by Rh incompatibility.
D. Infant who is Rh positive and whose mother is Rh positive.
Thisis wrong because if both the mother and the baby are Rh-positive, there is no risk of Rh incompatibility.
Full Explanation
choice A.
Infant of an Rh-negative mother and a father who is Rh-positive and homozygous for the Rh factor.
Rh incompatibility occurs when a woman is Rh-negative and her baby is Rh-positive. This can cause hemolytic disease of the neonate (HDN), a condition where the mother’s antibodies destroy the baby’s red blood cells.
Choice B is wrong because if both the mother and the baby are Rh-negative, there is no risk of Rh incompatibility.
Choice C is wrong because if the father is heterozygous for the Rh factor, there is a 50% chance that the baby will be Rh-negative and not affected by Rh incompatibility.
Choice D is wrong because if both the mother and the baby are Rh-positive, there is no risk of Rh incompatibility.
Human immunodeficiency virus (HIV) may be perinatally transmitted:
A. Only in the third trimester from the maternal circulation.
This is wrong because HIV can be transmitted at any stage of pregnancy, not only in the third trimester.
B. By a needlestick injury at birth from unsterile instruments.
This is wrong because needlestick injury is not a common mode of perinatal transmission of HIV. It is more likely to occur among healthcare workers who are exposed to contaminated needles or sharp objects.
C. Only through the ingestion of amniotic fluid.
This is wrong because HIV can also be transmitted through the ingestion of amniotic fluid, but it is not the only way. Amniotic fluid is the fluid that surrounds and protects the baby in the womb.
D. Through the ingestion of breast milk from an infected mother.
Perinatal transmission of HIV is when HIV is passed from a woman with HIV to her child during pregnancy, childbirth, or breastfeeding. Breast milk from an infected mother can contain HIV and infect the baby.
Full Explanation
The correct answer is choice D. Perinatal transmission of HIV is when HIV is passed from a woman with HIV to her child during pregnancy, childbirth, or breastfeeding.
Breast milk from an infected mother can contain HIV and infect the baby.
Choice A is wrong because HIV can be transmitted at any stage of pregnancy, not only in the third trimester.
Choice B is wrong because needlestick injury is not a common mode of perinatal transmission of HIV. It is more likely to occur among health care workers who are exposed to contaminated needles or sharp objects.
Choice C is wrong because HIV can also be transmitted through the ingestion of amniotic fluid, but it is not the only way. Amniotic fluid is the fluid that surrounds and protects the baby in the womb.