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

Bowel sounds

Respiratory rate

Temperature

Fetal heart rate (FHR)

Answer and Explanation

The Correct Answer is B

Choice A Reason:

While assessing bowel sounds is important for overall patient care, it is not the priority when administering magnesium sulfate. Magnesium sulfate is primarily used to prevent seizures in preeclampsia and to manage preterm labor. Its side effects can include respiratory depression, making respiratory rate the most critical assessment.

Choice B Reason:

Respiratory rate is the priority assessment when administering magnesium sulfate. Magnesium sulfate can cause respiratory depression, which can be life-threatening. Monitoring the respiratory rate helps ensure that the client is not experiencing adverse effects from the medication. The normal respiratory rate for adults is 12-20 breaths per minute.

Choice C Reason:

Temperature monitoring is important for detecting infections and other conditions, but it is not the priority in this context. Magnesium sulfate does not typically affect body temperature, so this assessment is less critical compared to respiratory rate.

Choice D Reason:

Fetal heart rate (FHR) monitoring is crucial for assessing fetal well-being, especially in clients with preeclampsia or preterm labor. However, the immediate priority when administering magnesium sulfate is to monitor the mother’s respiratory rate to prevent respiratory depression.

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Correct Answer is C

Explanation

Choice A Reason:

Allowing the grandmother to push the baby to the room in a wheeled bassinet is not advisable. Hospitals have strict protocols to prevent infant abduction, and only authorized personnel should transport newborns. This ensures the safety and security of the infant.

Choice B Reason:

Requiring photo identification from the grandmother before allowing her to take the infant is not a standard practice. While identification is crucial, it is typically the responsibility of the hospital staff to transport the newborn to ensure proper security measures are followed.

Choice C Reason:

Having the mother call and the nurse taking the baby to the room is the most appropriate response. This ensures that the newborn is transported safely by authorized personnel, adhering to hospital protocols designed to prevent infant abduction and ensure the baby’s safety.

Choice D Reason:

Allowing the grandmother to carry the grandchild to the room is not recommended. Similar to choice A, this does not align with hospital security protocols. Only authorized personnel should handle the transportation of newborns within the hospital to maintain safety and security.

A. Dry the newborn with a warm blanket. B. Close the doors to the delivery room. C. Wrap the newborn in a blanket. D. Place the newborn on a warm crib pad.

Correct Answer is D

Explanation

Choice A reason:

Drying the newborn with a warm blanket is an effective method to prevent heat loss through evaporation, not conduction. Evaporation occurs when moisture on the baby’s skin turns into vapor, which can cool the baby down. Using a warm blanket to dry the newborn helps to remove this moisture and keep the baby warm, but it does not specifically address heat loss via conduction.

Choice B reason:

Closing the doors to the delivery room helps to maintain a warm environment and prevent drafts, which can reduce heat loss through convection. Convection is the transfer of heat through air currents, and keeping the room warm can help to minimize this type of heat loss. However, this action does not directly address heat loss via conduction.

Choice C reason:

Wrapping the newborn in a blanket is another method to prevent heat loss through radiation and convection. By wrapping the baby, you create a barrier that helps to retain the baby’s body heat and protect against cooler air temperatures. While this is important for overall warmth, it does not specifically target heat loss via conduction.

Choice D reason:

Placing the newborn on a warm crib pad is the most effective method to prevent heat loss via conduction. Conduction is the transfer of heat from the baby’s body to a cooler surface. By using a warm crib pad, you ensure that the surface in contact with the baby is warm, thereby reducing the amount of heat lost through conduction. This method directly addresses the issue of heat loss via conduction and helps to keep the newborn warm.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

After assisting with a vaginal delivery, what would the nurse do to prevent heat loss via conduction in the newborn?

Correct Answer is D

Explanation

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