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A pregnant woman has been receiving a magnesium sulfate infusion for the treatment of severe preeclampsia for 24 hours.
On assessment, the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus.

The patient complains, “I’m so thirsty and warm.” The nurse:

Calls for a stat magnesium sulfate level

Administers oxygen

Discontinues the magnesium sulfate infusion

Prepares to administer hydralazine

Answer and Explanation

The Correct Answer is C

The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing.

Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely.

The nurse should stop the infusion immediately and notify the provider.

Choice A is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity.

The nurse should act quickly to prevent further complications.

Choice B is wrong because administering oxygen will not reverse the effects of magnesium toxicity.

Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.

Choice D is wrong because hydralazine is an antihypertensive medication that lowers blood pressure.

The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg).

Hydralazine may cause hypotension and fetal distress.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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Correct Answer is D

Explanation

Ulcerative colitis is a chronic inflammatory bowel disease that causes diarrhea, pain, and bleeding in the colon. Stress and certain foods can trigger or worsen the symptoms, so it is important to teach the mother how to help her son cope with stress and avoid triggers.

Choice A is wrong because ulcerative colitis is not an infectious disease that can spread to others.

Choice B is wrong because ulcerative colitis causes diarrhea, not constipation. Nutritional guidance is important, but not the main focus of teaching.

Choice C is wrong because the daily use of enemas is not part of the treatment plan for ulcerative colitis. Enemas can irritate the colon and cause more inflammation.

A. Apply an oil-based lotion to the newborn’s skin to prevent drying and cracking. B. Limit the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea. C. Place eye shields over the newborn’s closed eyes. D. Change the newborn’s position every 4 hours.

Correct Answer is C

Explanation

Placing eye shields over the newborn’s closed eyes. This is because phototherapy can cause eye damage and irritation to the newborn, so eye protection is essential.

Choice A is wrong because oil-based lotion can increase the absorption of heat and cause burns to the newborn’s skin.

Choice B is wrong because limiting the newborn’s intake of milk can cause dehydration and increase the risk of hyperbilirubinemia.

Choice D is wrong because changing the newborn’s position every 4 hours is not frequent enough to prevent pressure ulcers and ensure even exposure to the light.

Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL for term infants and 3 to 14 mg/dL for preterm infants. Phototherapy is usually indicated when the bilirubin level exceeds 15 mg/dL for term infants and 10 mg/dL for preterm infants.

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Naxlex Comprehensive Predictor Exams

What should the nurse stress in a teaching plan for the mother of an 11-year-old diagnosed with ulcerative colitis?

Correct Answer is D

Explanation

A newborn is jaundiced and receivesphototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

Correct Answer is C

Explanation

A woman is in her seventh month of pregnancy. She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:

The nurse is assessing a child with acute epiglottitis. Examining the child’s throat by using a tongue depressor might precipitate which symptom or condition?

Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply.):.

It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently to monitor for increased risk of:

A child is diagnosed with juvenile hypothyroidism. The nurse should expect to assess which symptoms are associated with hypothyroidism. (Select all that apply.).​​​​​​

What is the nurse’s first action when planning to teach the parents of an infant with a congenital heart defect (CHD)?

A nurse is conducting discharge and teaches parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if the conditions occur. (Select all that apply.)