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 D

Explanation

A. Incorrect. The newborn’s temperature should be monitored more frequently, typically every 2-4 hours during phototherapy to prevent hypothermia or hyperthermia.

B. Incorrect. Moisturizing lotion is not recommended because it can interfere with the effectiveness of phototherapy by blocking the light.

C. Incorrect. Glucose water is not routinely given to newborns during phototherapy. Proper hydration and feeding are managed differently.

D. Correct. Repositioning the newborn every 2-3 hours during phototherapy is important to ensure even exposure to the light and prevent skin breakdown.

A. Nulliparity B. History of breastfeeding C. Previous use of oral contraceptives D. History of breast cancer E. Use of postmenopausal estrogen

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

Explanation

A. Nulliparity: Correct. Nulliparity, or never having been pregnant, is a known risk factor for ovarian cancer. Women who have never given birth have a higher risk of developing ovarian cancer compared to those who have had one or more children.

B. History of breastfeeding: Incorrect. Breastfeeding is generally associated with a decreased risk of ovarian cancer. It is thought to reduce the number of lifetime ovulatory cycles, thereby potentially lowering the risk.

C. Previous use of oral contraceptives: Incorrect. The use of oral contraceptives is associated with a reduced risk of ovarian cancer. Long-term use can significantly decrease the risk, and the protective effect may continue for years after discontinuation.

D. History of breast cancer: Correct. A history of breast cancer is a risk factor for ovarian cancer, particularly in women with BRCA1 or BRCA2 gene mutations. These mutations increase the risk of both breast and ovarian cancers.

E.Use of postmenopausal estrogen: Correct. The use of postmenopausal estrogen, especially when used without progesterone, is associated with an increased risk of ovarian cancer. Estrogen therapy can stimulate the growth of ovarian tumors in susceptible women.

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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

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