A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

Respiratory rate 11/min

Deep tendon reflexes 2+

Urine output 30 mL/hr

Blood pressure 100/62 mm Hg

Answer and Explanation

The Correct Answer is A

A. Respiratory rate 11/min: Correct. A respiratory rate of 11/min is below the normal range and could indicate magnesium sulfate toxicity, which can depress respiratory function. This finding requires prompt reporting to prevent further complications.

B. Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.

C. Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.

D. Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.

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Correct Answer is ["A","E"]

Explanation

A. Instruct the client to wash their hands prior to breastfeeding: Correct. Proper hand hygiene helps to prevent the spread of infection, which is important for a client with mastitis. Washing hands before breastfeeding is a crucial infection control measure.

B. Teach the client about proper latching-on techniques: Correct. Proper latching-on techniques can help prevent further complications and ensure effective milk removal, which can help in managing mastitis and preventing recurrence.

C. Encourage the client to alternate breastfeeding with formula feeding: Incorrect. Breastfeeding should continue as usual because it helps to empty the breast and relieve engorgement, which is crucial for managing mastitis. Formula feeding could exacerbate the problem by increasing engorgement.

D. Instruct the client to avoid using a breast pump: Incorrect. Using a breast pump can be beneficial for managing mastitis by helping to relieve engorgement and ensure proper milk drainage. The pump should be used correctly and hygienically.

E. Encourage the client to allow their nipples to air dry after feedings: Correct. Allowing the nipples to air dry helps prevent further irritation and infection. It is important for maintaining skin integrity and comfort during mastitis.

A. Polyuria B. Hypertension C. Pruritus D. Dry mouth

Correct Answer is C

Explanation

A. Incorrect. Polyuria is not typically associated with epidural anesthesia. The adverse effects of epidurals are more related to cardiovascular and central nervous system impacts.

B. Incorrect. Epidural anesthesia generally causes hypotension, not hypertension, due to vasodilation.

C. Correct. Pruritus (itchiness) is a known adverse effect of epidural anesthesia, particularly if opioids are used in the epidural.

D. Incorrect. Dry mouth is not a common adverse effect of epidural anesthesia. It is more often associated with other medications or conditions.

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A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?

Correct Answer is C

Explanation

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