A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)

Evaluate fetal heart rate and contraction patterns.

Obtain prescription to repeat hepatic panel.

Monitor for evidence of seizure activity.

Check the urinary output in hourly urinometer.

Inspect the perineum for vaginal bleeding.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.

Choice B rationale

Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.

Choice C rationale

Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.

Choice D rationale

Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.

Choice E rationale

Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.

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Correct Answer is A

Explanation

Choice A rationale

Erythromycin ointment is effective for preventing ophthalmia neonatorum, a severe eye infection caused by Neisseria gonorrhoeae. It reduces the risk of blindness by inhibiting bacterial growth in the newborn's eyes.

Choice B rationale

Neomycin is not effective against Neisseria gonorrhoeae and is not recommended for preventing ophthalmia neonatorum. It is typically used for skin infections and lacks efficacy in this scenario.

Choice C rationale

Tetracaine is a topical anesthetic used for numbing the eyes. It does not possess antibacterial properties required to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.

Choice D rationale

Latanoprost is a prostaglandin analog used to treat glaucoma by reducing intraocular pressure. It does not have antibacterial properties to prevent ophthalmia neonatorum in newborns.

A. Passive immunity in the first months of life provides protection in newborns. B. Infants can receive antiinfectants that have not developed resistance to microbes. C. Active immunity in newborns is developed fully in the first month of life. D. Neutrophils may be immature in protecting neonates from the risk for infection.

Correct Answer is A

Explanation

Choice A rationale

Passive immunity provided by maternal antibodies crossing the placenta and through breast milk protects newborns in the first months of life, offering initial defense against communicable diseases.

Choice B rationale

Antiinfectants effectiveness against microbes does not apply; newborns rely on passive immunity as their adaptive immune system matures, not unresistant antiinfectants.

Choice C rationale

Active immunity develops over several months to years in newborns, as their immune system gradually encounters pathogens and develops specific responses.

Choice D rationale

While neutrophils are part of the innate immune system, they may still be immature and insufficient in preventing infections in neonates without maternal antibody support.

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A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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