A nurse is caring for a client who is suspected to have an ectopic pregnancy at 8 weeks of gestation. What symptoms should the nurse expect to observe that are consistent with this diagnosis?

Unilateral, cramp-like abdominal pain.

Severe nausea and vomiting.

Uterine enlargement greater than expected for gestational age.

Large amount of vaginal bleeding.

Answer and Explanation

The Correct Answer is A

Choice A rationale

An ectopic pregnancy, where the fertilized egg attaches outside the uterus, often presents with unilateral, cramp-like abdominal pain. This is because as the fertilized egg grows in an area where it cannot survive, it can cause irritation and bleeding, leading to pain. This pain is often one-sided or unilateral and can vary from mild to severe. It’s one of the key symptoms that can suggest an ectopic pregnancy in the early weeks of gestation.

Choice B rationale

Severe nausea and vomiting are not typically the primary symptoms associated with an ectopic pregnancy. While nausea can be a symptom of early pregnancy, severe nausea and vomiting alone without other symptoms would not necessarily indicate an ectopic pregnancy.

Choice C rationale

Uterine enlargement greater than expected for gestational age is not a symptom of an ectopic pregnancy. In fact, because the pregnancy is not in the uterus, the size of the uterus may not correlate with the expected size at the given gestational age.

Choice D rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is not typically a large amount. The bleeding is often lighter than normal menstrual bleeding and may be associated with a change in color of the vaginal discharge.

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Correct Answer is C

Explanation

The correct answer is choice C: Respiratory rate.

Choice A rationale:

Fetal heart rate (FHR) is an important assessment for clients experiencing preterm labor, but it is not the priority assessment when administering magnesium sulfate. FHR monitoring is crucial to ensure fetal well-being but is not directly related to the potential adverse effects of magnesium sulfate.

Choice B rationale:

Temperature is an essential assessment parameter, but it is not the priority in this case. Magnesium sulfate administration can cause adverse effects, particularly on the respiratory system, which should be closely monitored.

Choice C rationale:

Respiratory rate is the correct choice because respiratory rate is a priority assessment when administering magnesium sulfate. The drug can cause respiratory depression and other respiratory complications, so monitoring the respiratory rate is essential to ensure the client's safety.

Choice D rationale:

Bowel sounds are not a priority assessment for a client receiving magnesium sulfate. While gastrointestinal side effects can occur with magnesium sulfate use, respiratory assessments take precedence.

In conclusion, the priority nursing assessment for a client receiving magnesium sulfate is the respiratory rate due to the potential respiratory complications associated with the drug. Monitoring respiratory function closely can help prevent adverse outcomes and ensure the client's safety during treatment.

A. Prepare for an emergency cesarean birth B. Position the client in Trendelenburg C. Discontinue the medication infusion D. Assess maternal blood glucose

Correct Answer is C

Explanation

Choice A rationale

Preparing for an emergency cesarean birth may be necessary in some cases of preeclampsia, particularly if there are signs of fetal distress or if the condition is not responding to treatment. However, in this scenario, the client’s symptoms are indicative of magnesium toxicity, not worsening preeclampsia.

Choice B rationale

Positioning the client in Trendelenburg (with the head lower than the feet) is not typically used in the management of preeclampsia or magnesium toxicity.

Choice C rationale

Discontinuing the medication infusion is the correct action in this scenario. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) are indicative of magnesium toxicity, a potential complication of magnesium sulfate therapy. Magnesium sulfate is used in the management of preeclampsia to prevent seizures, but it can cause toxicity if the levels become too high. If signs of toxicity occur, the infusion should be discontinued immediately.

Choice D rationale

Assessing maternal blood glucose may be necessary in some cases, particularly if the client has a history of diabetes. However, it is not the priority in this scenario, as the client’s symptoms are indicative of magnesium toxicity, not hyperglycemia.

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A nurse is caring for a client who is suspected to have an ectopic pregnancy at 8 weeks of gestation. What symptoms should the nurse expect to observe that are consistent with this diagnosis?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is C

Explanation

A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent. What action should the nurse take?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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