A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

Severe nausea and vomiting.

Pelvic pain.

Uterine enlargement greater than expected for gestational age.

Copious vaginal bleeding.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.

Choice B rationale:
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.

Choice C rationale:
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.

Choice D rationale:
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.

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Correct Answer is A

Explanation

The correct answer is choice A: Respiratory rate of 16/min.

Choice A rationale:

A respiratory rate of 16/min is within the normal range for adults, which is typically between 12 to 20 breaths per minute. In the context of severe preeclampsia, maintaining a normal respiratory rate is crucial when administering magnesium sulfate IV, as one of the signs of magnesium toxicity is respiratory depression. Therefore, a respiratory rate of 16/min indicates that the client is not experiencing respiratory depression and it is safe to continue the magnesium sulfate infusion.

Choice B rationale:

A heart rate of 60/min is at the lower end of the normal range, which is 60 to 100 beats per minute for adults. However, bradycardia or a low heart rate can be a sign of magnesium sulfate toxicity, especially if accompanied by other symptoms such as hypotension or altered mental status. Without additional context, a heart rate of 60/min alone does not necessarily indicate it is unsafe to continue the infusion, but it would require further assessment.

Choice C rationale:

A urine output of 50 mL in 4 hours is significantly below the expected minimum of 30 mL/hour for adults. Adequate urine output is an important indicator of kidney function and is essential for the excretion of magnesium. In the case of magnesium sulfate infusion for severe preeclampsia, a low urine output could indicate renal insufficiency and an increased risk of magnesium toxicity. Therefore, a urine output of 50 mL in 4 hours is a contraindication for continuing the infusion without further evaluation.

Choice D rationale:

Diminished deep-tendon reflexes can be a sign of magnesium toxicity. Deep-tendon reflexes are assessed to monitor for signs of magnesium overdose during infusion, as magnesium acts as a central nervous system depressant at high levels. If deep-tendon reflexes are diminished, it may suggest that the serum magnesium levels are too high, and the infusion should be paused or discontinued to prevent further toxicity.

In summary, the only finding that clearly indicates it is safe to continue the magnesium sulfate infusion is a normal respiratory rate, as provided in choice A. The other options either require further assessment or are indicators of potential magnesium toxicity.

A. Place a soft pillow under the client's buttocks. B. Apply an ice pack to the perineum. C. Position a heating lamp toward the episiotomy. D. Prepare a warm sitz bath.

Correct Answer is B

Explanation

The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.

Choice A rationale:

Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.

Choice B rationale:

Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.

Choice D rationale:

While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.

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A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Correct Answer is A

Explanation

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse reinforcing teaching about vitamin K with a client who is postpartum. Which of the following statements should the nurse include?

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