A client in preterm labor has had an infusion of magnesium sulfate running for 8 hours.
Current assessment findings are respirations of 14 breaths/minute, a urine output of 25 mL/hr, deep tendon reflexes of 1+, and a serum magnesium level of 8 mEq/L (4 mmol/L). Based on these assessment findings, which conclusion should the nurse reach?

These findings are within normal limits and require routine follow-up.

All findings are outside of the acceptable range and should be reported to the healthcare provider immediately.

The primary IV fluids should be increased to assist in increasing the urinary output.

The findings indicate potential toxicity to the magnesium sulfate and close follow-up is indicated.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.

Choice B rationale

Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.

Choice C rationale

Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.

Choice D rationale

The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale

Telling the child that you're glad the mother explained the procedure doesn't provide the child with an opportunity to express their understanding or concerns. It is important to engage the child directly to understand what they know and how they feel about the operation, rather than relying solely on what the parent has communicated.

Choice B rationale

Asking the child to explain what an operation is allows the nurse to gauge the child's understanding and provides an opportunity to correct any misconceptions. This approach also encourages open communication and helps the child feel more involved and informed about their own care, which can reduce anxiety.

Choice C rationale

Reassuring the child that the hospital staff will take very good care of them is comforting, but it doesn't address the child's need for information and understanding about the operation. While it's important to provide reassurance, the primary focus should be on ensuring the child comprehends what will happen.

Choice D rationale

Directly asking the child if they are scared might lead to a yes or no answer, and doesn't necessarily encourage them to share their specific fears or concerns. It is more effective to ask open-ended questions that allow the child to express their feelings in more detail, which can then be addressed by the nurse.

A. Increasing intake of protein might improve these values. B. Plasma volume increases, making the blood count appear low. C. It might be necessary to take an iron supplement twice daily. D. Almost all women at 28-weeks gestation have anemia.

Correct Answer is B

Explanation

Choice A rationale

While increasing protein intake is beneficial for overall health and pregnancy, it is not the primary factor that affects hemoglobin and hematocrit levels. These levels are more directly influenced by iron intake and the physiological changes during pregnancy. Protein intake is important for fetal growth and development, but it does not significantly alter the concentration of hemoglobin or hematocrit in the blood.

Choice B rationale

During pregnancy, plasma volume increases by approximately 50%, leading to hemodilution. This means that even though the total number of red blood cells increases, the concentration of hemoglobin and hematocrit appears lower due to the larger volume of plasma. This physiological change helps meet the increased oxygen demands of both the mother and the growing fetus and is a normal part of pregnancy.

Choice C rationale

Taking an iron supplement can help improve hemoglobin and hematocrit levels, especially if a pregnant woman has iron-deficiency anemia. Iron is essential for the production of hemoglobin, which carries oxygen in the blood. However, not all pregnant women with lower hemoglobin and hematocrit levels need to take iron supplements, as these values can be within the expected range for pregnancy. The decision to supplement should be based on individual assessment by a healthcare provider.

Choice D rationale

Not all women at 28 weeks gestation have anemia. While it is common for hemoglobin and hematocrit levels to be lower during pregnancy due to increased plasma volume, it does not mean that all pregnant women are anemic. Anemia is diagnosed based on specific thresholds for hemoglobin and hematocrit levels, and the values mentioned (hemoglobin 10.7 g/dL and hematocrit 32%) are borderline and may not necessarily indicate anemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the admission process of a school-age child, the child states, "I'm going to have an operation.”. Which response is best for the nurse to provide to this child?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?

The nurse is caring for a child with a unilateral long-leg cast applied for the correction of clubfoot. Which action is most important for the nurse to perform?

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?

The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?