Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a 30-week gestation client who was loaded on a magnesium sulfate infusion one hour ago for preterm labor. Which of the following assessment findings would warrant the infusion to be discontinued immediately?
A. Blood pressure of 138/88.
B. Urinary output of 40 ml/hr.
C. Respiratory rate of 10 breaths/minute.
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
D. Patellar reflex of +2.
This question is an excerpt from Nurse Dive's nursing test bank - Final Exam OB + Community Proctored Exam. Take the full exam now
Full Explanation
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
Similar Questions
Educating a client about starting nifedipine (Procardia) for preterm labor prevention, the nurse knows that her educational plan for this client should include which of the following?
A. Your respiratory rate may slow down, so make sure to monitor your breathing rate!
B. You will most likely be hospitalized until delivery while on your medication
C. You should try to get up slowly and drink plenty of fluids
Nifedipine is a calcium channel blocker that can cause hypotension as a side effect, so the client should be advised to rise slowly from a sitting or lying position to avoid dizziness or fainting. The client does not necessarily need to be hospitalized and should continue taking the medication until a healthcare provider advises otherwise. The medication is typically continued until around 36-37 weeks gestation. There is no need to monitor respiratory rate with this medication.
D. You will stop this medication at 28 weeks.
Full Explanation
Nifedipine is a calcium channel blocker that can cause hypotension as a side effect, so the client should be advised to rise slowly from a sitting or lying position to avoid dizziness or fainting. The client does not necessarily need to be hospitalized and should continue taking the medication until a healthcare provider advises otherwise. The medication is typically continued until around 36-37 weeks gestation. There is no need to monitor respiratory rate with this medication.
A woman in preterm labor at 30 weeks of gestation receives two 12 mg doses of betamethasone (Celestane) intramuscularly. The purpose of this pharmacologic treatment is to:
A. Reduce maternal and fetal tachycardia associated with terbutaline administration.
B. Suppress uterine contractions.
C. Stimulate fetal surfactant production.
Betamethasone is a corticosteroid that enhances fetal lung maturity, which can help reduce the risk of respiratory distress syndrome and other complications in preterm infants. It does not reduce maternal and fetal tachycardia associated with terbutaline administration, suppress uterine contractions, or maintain maternal respiratory effort and ventilation during magnesium sulfate therapy.
D. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
Full Explanation
Betamethasone is a corticosteroid that enhances fetal lung maturity, which can help reduce the risk of respiratory distress syndrome and other complications in preterm infants. It does not reduce maternal and fetal tachycardia associated with terbutaline administration, suppress uterine contractions, or maintain maternal respiratory effort and ventilation during magnesium sulfate therapy.
A client has completed the 3-hour oral glucose tolerance test (GTT) after failing the initial screening. The nurse notes the client has failed the 2-hour and 3-hour tests. The nurse anticipates that the client will:
A. Continue routine prenatal care.
B. Be referred to an endocrinologist.
In some cases, an endocrinologist may also be involved in the management of gestational diabetes. The nurse can anticipate that the client will be diagnosed with gestational diabetes and will be referred to a dietician for dietary modifications and glucose monitoring during the remainder of her pregnancy. Regular prenatal care will also continue, and the healthcare provider may adjust the treatment plan based on the client's individual needs. However, a diagnosis of Type II diabetes would not be made solely based on a failed GTT during pregnancy, as gestational diabetes is a temporary condition that usually resolves after delivery.
C. Be diagnosed with Type II diabetes.
D. Be referred to a dietician.
Full Explanation
In some cases, an endocrinologist may also be involved in the management of gestational diabetes. The nurse can anticipate that the client will be diagnosed with gestational diabetes and will be referred to a dietician for dietary modifications and glucose monitoring during the remainder of her pregnancy. Regular prenatal care will also continue, and the healthcare provider may adjust the treatment plan based on the client's individual needs.
However, a diagnosis of Type II diabetes would not be made solely based on a failed GTT during pregnancy, as gestational diabetes is a temporary condition that usually resolves after delivery.