Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
A) is unnecessary in this situation. The symptoms described - increased temperature, pulse rate, and blood pressure, along with absent deep tendon reflexes - indicate magnesium sulfate toxicity. Discontinuing the infusion and managing the symptoms take precedence over checking the magnesium sulfate level.
B. administers oxygen.
B) is important for maintaining the patient's oxygenation levels, but it does not address the magnesium sulfate toxicity. The primary intervention should be to discontinue the infusion and manage the symptoms.
C. discontinues the magnesium sulfate infusion.
C) is the correct action in this situation. The symptoms, including absent deep tendon reflexes and the patient's complaint of thirst and warmth, indicate magnesium sulfate toxicity. Stopping the infusion is crucial to prevent further complications.
D. prepares to administer hydralazine.
D) is an antihypertensive medication and is not the appropriate intervention for magnesium sulfate toxicity. Managing magnesium sulfate toxicity involves discontinuing the infusion and providing supportive care.
This question is an excerpt from Nurse Dive's nursing test bank - International College of Health Sciences ICHS OB Pediatrics Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
A stat magnesium sulfate level (Choice A) is unnecessary in this situation. The symptoms described - increased temperature, pulse rate, and blood pressure, along with absent deep tendon reflexes - indicate magnesium sulfate toxicity. Discontinuing the infusion and managing the symptoms take precedence over checking the magnesium sulfate level.
Choice B rationale:
Administering oxygen (Choice B) is important for maintaining the patient's oxygenation levels, but it does not address the magnesium sulfate toxicity. The primary intervention should be to discontinue the infusion and manage the symptoms.
Choice C rationale:
Discontinuing the magnesium sulfate infusion (Choice C) is the correct action in this situation. The symptoms, including absent deep tendon reflexes and the patient's complaint of thirst and warmth, indicate magnesium sulfate toxicity. Stopping the infusion is crucial to prevent further complications.
Choice D rationale:
Hydralazine (Choice D) is an antihypertensive medication and is not the appropriate intervention for magnesium sulfate toxicity. Managing magnesium sulfate toxicity involves discontinuing the infusion and providing supportive care.
Similar Questions
Magnesium sulfate is given to women with preeclampsia and eclampsia to.
A. improve patellar reflexes and increase respiratory efficiency.
A). It is primarily used to prevent and treat seizures (convulsions) in patients with preeclampsia and eclampsia.
B. shorten the duration of labor.
B). Its use is not related to the progression of labor but rather to prevent and control seizures in the context of preeclampsia and eclampsia.
C. prevent and treat convulsions.
C) is the main indication for administering magnesium sulfate in cases of severe preeclampsia and eclampsia. Magnesium sulfate acts as a central nervous system depressant, reducing the risk of seizures in these patients.
D. prevent a boggy uterus and lessen lochial flow.
D) are unrelated to the use of magnesium sulfate. These concerns are typically managed through uterine massage and other postpartum care measures, not magnesium sulfate administration.
Full Explanation
Choice A rationale:
Magnesium sulfate is not given to improve patellar reflexes and increase respiratory efficiency (Choice A). It is primarily used to prevent and treat seizures (convulsions) in patients with preeclampsia and eclampsia.
Choice B rationale:
Magnesium sulfate does not shorten the duration of labor (Choice B). Its use is not related to the progression of labor but rather to prevent and control seizures in the context of preeclampsia and eclampsia.
Choice C rationale:
Preventing and treating convulsions (Choice C) is the main indication for administering magnesium sulfate in cases of severe preeclampsia and eclampsia. Magnesium sulfate acts as a central nervous system depressant, reducing the risk of seizures in these patients.
Choice D rationale:
Preventing a boggy uterus and lessening lochial flow (Choice D) are unrelated to the use of magnesium sulfate. These concerns are typically managed through uterine massage and other postpartum care measures, not magnesium sulfate administration.
After an emergency birth, the nurse encourages the woman to breastfeed her newborn.
The primary purpose of this activity is to:.
A. Facilitate maternal-newborn interaction.
Facilitate maternal-newborn interaction. Facilitating maternal-newborn interaction is an important aspect of breastfeeding, but it is not the primary purpose of encouraging breastfeeding immediately after an emergency birth. The primary purpose is to initiate the lactation cycle, allowing the newborn to receive essential colostrum, the first milk rich in antibodies and nutrients, which aids in the development of the newborn's immune system.
B. Stimulate the uterus to contract.
Stimulate the uterus to contract. While breastfeeding can stimulate uterine contractions due to oxytocin release, the primary purpose of encouraging breastfeeding in this context is not to contract the uterus but to initiate the lactation cycle for the newborn's benefit.
C. Prevent neonatal hypoglycemia.
Prevent neonatal hypoglycemia. Breastfeeding can help prevent neonatal hypoglycemia by providing the newborn with a constant supply of nutrients, but the primary purpose immediately after an emergency birth is to initiate the lactation cycle and provide colostrum, not solely to prevent hypoglycemia.
D. Initiate the lactation cycle.
Initiate the lactation cycle. Initiating the lactation cycle is the correct answer because breastfeeding immediately after birth helps the woman's body start producing milk and provides the newborn with colostrum, essential for their health and development. Colostrum is rich in antibodies and nutrients, offering vital protection and nourishment to the newborn.
Full Explanation
Choice A rationale:
Facilitate maternal-newborn interaction. Facilitating maternal-newborn interaction is an important aspect of breastfeeding, but it is not the primary purpose of encouraging breastfeeding immediately after an emergency birth. The primary purpose is to initiate the lactation cycle, allowing the newborn to receive essential colostrum, the first milk rich in antibodies and nutrients, which aids in the development of the newborn's immune system.
Choice B rationale:
Stimulate the uterus to contract. While breastfeeding can stimulate uterine contractions due to oxytocin release, the primary purpose of encouraging breastfeeding in this context is not to contract the uterus but to initiate the lactation cycle for the newborn's benefit.
Choice C rationale:
Prevent neonatal hypoglycemia. Breastfeeding can help prevent neonatal hypoglycemia by providing the newborn with a constant supply of nutrients, but the primary purpose immediately after an emergency birth is to initiate the lactation cycle and provide colostrum, not solely to prevent hypoglycemia.
Choice D rationale:
Initiate the lactation cycle. Initiating the lactation cycle is the correct answer because breastfeeding immediately after birth helps the woman's body start producing milk and provides the newborn with colostrum, essential for their health and development. Colostrum is rich in antibodies and nutrients, offering vital protection and nourishment to the newborn.
A laboring woman is lying in the supine position.
The most appropriate nursing action at this time is to:.
A. Ask her to turn to one side.
Ask her to turn to one side. The supine position during labor can compress the vena cava, reducing blood flow to the uterus and potentially compromising fetal oxygenation. Turning the woman to her side, especially the left side, can relieve this pressure and improve blood flow to the uterus, ensuring adequate oxygen supply to the fetus. This position change is crucial for the well-being of both the mother and the baby during labor.
B. Elevate her feet and legs.
Elevate her feet and legs. Elevating the woman's feet and legs might not be effective in relieving the pressure on the vena cava, as it does not change the orientation of the uterus in relation to the vena cava. Turning the woman to her side is a more appropriate and effective action to improve blood flow to the uterus and fetus.
C. Take her blood pressure.
Take her blood pressure. While monitoring the woman's blood pressure is essential during labor, it is not the most appropriate action in this situation. The priority is to relieve the compression of the vena cava by changing the woman's position.
D. Determine whether fetal tachycardia is present.
Determine whether fetal tachycardia is present. Monitoring the fetal heart rate is crucial during labor, but the woman's position should be the immediate concern if she is lying in the supine position. Changing her position to relieve the vena cava compression takes precedence to ensure adequate oxygenation to the fetus.
Full Explanation
Choice A rationale:
Ask her to turn to one side. The supine position during labor can compress the vena cava, reducing blood flow to the uterus and potentially compromising fetal oxygenation. Turning the woman to her side, especially the left side, can relieve this pressure and improve blood flow to the uterus, ensuring adequate oxygen supply to the fetus. This position change is crucial for the well-being of both the mother and the baby during labor.
Choice B rationale:
Elevate her feet and legs. Elevating the woman's feet and legs might not be effective in relieving the pressure on the vena cava, as it does not change the orientation of the uterus in relation to the vena cava. Turning the woman to her side is a more appropriate and effective action to improve blood flow to the uterus and fetus.
Choice C rationale:
Take her blood pressure. While monitoring the woman's blood pressure is essential during labor, it is not the most appropriate action in this situation. The priority is to relieve the compression of the vena cava by changing the woman's position.
Choice D rationale:
Determine whether fetal tachycardia is present. Monitoring the fetal heart rate is crucial during labor, but the woman's position should be the immediate concern if she is lying in the supine position. Changing her position to relieve the vena cava compression takes precedence to ensure adequate oxygenation to the fetus.