A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?

Assess maternal blood glucose.

Discontinue the magnesium infusion.

Prepare for an emergency cesarean birth.

Place the client in Trendelenburg position.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Assessing maternal blood glucose is important in various clinical scenarios, such as managing diabetes during pregnancy. However, it is not directly related to the immediate issue of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min is a critical sign that requires immediate intervention to prevent further complications.

Choice B reason:

Discontinuing the magnesium infusion is the priority intervention. Magnesium sulfate toxicity can lead to severe respiratory depression, hypotension, and loss of deep tendon reflexes. A respiratory rate of 10/min indicates significant respiratory depression, which can be life-threatening. Stopping the infusion immediately helps to prevent further accumulation of magnesium in the body and allows for the administration of the antidote, calcium gluconate, if necessary.

Choice C reason:

Preparing for an emergency cesarean birth is a critical intervention in cases of fetal distress or other obstetric emergencies. However, in this scenario, the immediate concern is the client’s respiratory depression due to magnesium sulfate toxicity. Addressing the respiratory issue takes precedence to stabilize the client before considering any surgical interventions.

Choice D reason:

Placing the client in Trendelenburg position is typically used to treat hypotension or shock by promoting venous return to the heart. While it can be beneficial in certain situations, it does not address the primary issue of respiratory depression caused by magnesium sulfate toxicity. The priority is to discontinue the magnesium infusion and manage the respiratory depression.

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Correct Answer is A

Explanation

Choice A reason:

The indirect Coombs test is used to detect Rh-positive antibodies in the mother’s blood. This test is crucial for Rh-negative mothers who have given birth to Rh-positive infants. It helps determine if the mother has been sensitized to Rh-positive blood and has developed antibodies against it. If these antibodies are present, they can cross the placenta in future pregnancies and attack the red blood cells of an Rh-positive fetus, leading to hemolytic disease of the newborn.

Choice B reason:

The statement “It determines the presence of maternal antibodies in the newborn’s blood” is incorrect. The indirect Coombs test is performed on the mother’s blood, not the newborn’s. It screens for antibodies that could potentially harm the fetus in future pregnancies. The direct Coombs test, on the other hand, is used to detect antibodies that are already attached to the newborn’s red blood cells.

Choice C reason:

The statement “It detects Rh-negative antibodies in the newborn’s blood” is incorrect. The indirect Coombs test does not detect Rh-negative antibodies in the newborn’s blood. Instead, it identifies antibodies in the mother’s blood that could react against Rh-positive red blood cells. This test helps in assessing the risk of hemolytic disease in future pregnancies.

Choice D reason:

The statement “It determines if kernicterus will occur in the newborn” is incorrect. Kernicterus is a severe form of jaundice caused by high levels of bilirubin in the blood. While the Coombs test can help identify hemolytic disease, which can lead to jaundice, it does not directly determine the risk of kernicterus. The primary purpose of the indirect Coombs test is to detect antibodies that could cause hemolytic disease in future pregnancies.

A. Ask the client if she has considered harming her newborn. B. Anticipate a prescription by the provider for an antidepressant. C. Reinforce postpartum and newborn care discharge teaching. D. Assist the family to identify proper use of positive coping skills in family crises.

Correct Answer is A

Explanation

Choice A Reason:

The priority action is to assess the safety of both the client and the newborn. Asking the client if she has considered harming her newborn is crucial to determine if there is an immediate risk of harm. This question helps identify any potential danger and allows for immediate intervention if necessary. Ensuring the safety of the mother and baby is the top priority in managing postpartum depression.

Choice B Reason:

Anticipating a prescription for an antidepressant is important, but it is not the immediate priority. Medication can be part of the treatment plan for postpartum depression, but first, it is essential to assess the client’s safety and risk of harm to herself or her newborn.

Choice C Reason:

Reinforcing postpartum and newborn care discharge teaching is beneficial for the client’s overall understanding and management of her condition. However, it does not address the immediate concern of potential harm to the newborn or the severity of the client’s depressive symptoms

Choice D Reason:

Assisting the family to identify proper use of positive coping skills is a valuable long-term strategy for managing postpartum depression. However, the immediate priority is to assess the client’s safety and ensure there is no risk of harm to herself or her newborn.

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A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is A

Explanation

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