A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation.

Exhibits
Which of the following actions should the nurse take after administering the prescribed medications? Select all that apply.

Keep calcium gluconate readily available.

Check urinary output every 2 hr.

Check deep tendon reflexes every 1 hr.

Provide intermittent fetal monitoring.

Report respiratory rate of less than 12 breaths/min to the provider.

Answer and Explanation

Correct Answer : A,B,C,E

A. Keep calcium gluconate readily available: Magnesium sulfate can cause toxicity, including respiratory depression and cardiac arrest. Calcium gluconate is the antidote and must be available at the bedside in case of adverse effects. This is a critical safety measure during therapy.

B. Check urinary output every 2 hr: Magnesium is excreted through the kidneys, so reduced urine output can lead to accumulation and toxicity. Monitoring urinary output ensures the client is clearing the medication effectively. Output should remain ≥30 mL/hr.

C. Check deep tendon reflexes every 1 hr: Loss of deep tendon reflexes is an early sign of magnesium toxicity. Hourly assessments help detect neuromuscular depression and guide dosage adjustments. Reflex monitoring is essential during magnesium infusion.

D. Provide intermittent fetal monitoring: This is inappropriate in the context of severe hypertension and magnesium sulfate administration. Continuous fetal monitoring is required to assess fetal well-being and detect signs of distress, especially in a high-risk situation.

E. Report respiratory rate of less than 12 breaths/min to the provider: Respiratory depression is a major sign of magnesium toxicity. A respiratory rate below 12 indicates central nervous system depression and requires immediate attention. Prompt reporting allows timely intervention to prevent complications.

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Correct Answer is B

Explanation

A. Weeks 25–36: This range falls within the third trimester of pregnancy. It includes the period of continued fetal growth and development, not the early developmental stages that define the first trimester.

B. Weeks 1–12: The first trimester spans from conception through the 12th week of gestation. This period includes critical fetal organ development, hormonal shifts, and early pregnancy symptoms such as nausea and fatigue.

C. Weeks 13–24: These weeks represent the second trimester, which is often marked by decreased early symptoms and increased fetal movement. It follows the completion of the first trimester at week 12.

D. Weeks 37–40: This time frame represents the late third trimester, also referred to as term pregnancy. It involves preparation for labor and delivery, not early fetal development.

A. G3 TO P2 A1 L1 B. G2 T1 PO AO L2 C. G2 T1 PO A1 L2 D. G3 T1 PO A1 L1

Correct Answer is D

Explanation

A. G3 T0 P2 A1 L1: This option incorrectly states that the client has had two preterm births, which she has not. She has had one full-term birth and one abortion, making the parity count inaccurate in this case.

B. G2 T1 P0 A0 L2: This count underrepresents the client’s total pregnancies (G2 instead of G3) and indicates no abortions, which contradicts the elective abortion at 9 weeks. It also incorrectly lists two living children instead of one.

C. G2 T1 P0 A1 L2: While it correctly lists the term birth and abortion, it inaccurately lists two living children and indicates the client has had only two pregnancies instead of three, making the gravida count incorrect.

D. G3 T1 P0 A1 L1: The client has had three pregnancies (G3), one term birth (T1), no preterm births (P0), one abortion (A1), and one living child (L1). This option accurately reflects her obstetric history using the GTPAL system.

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A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation. Exhibits Which of the following actions should the nurse take after administering the prescribed medications? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a newly pregnant client about the stages of pregnancy. The client asks, "Which weeks are included in the first trimester?" The nurse correctly responds with which of the following?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation.

Exhibits
Which of the following actions should the nurse take after administering the prescribed medications? Select all that apply.