The nurse is caring for a 30-week gestation client who was loaded on a magnesium sulfate infusion one hour ago for preterm labor. Which of the following assessment findings would warrant the infusion to be discontinued immediately?
Blood pressure of 138/88.
Urinary output of 40 ml/hr.
Respiratory rate of 10 breaths/minute.
Patellar reflex of +2.
The Correct Answer is C
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
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Correct Answer is B
Explanation
Caput succedaneum is a common condition in newborns that causes swelling of the soft tissues of the scalp. It is usually caused by pressure on the baby's head during delivery and can be seen in both vaginal and instrumental births, such as vacuum-assisted deliveries. It generally crosses the suture lines, unlike a cephalohematoma.
Caput succedaneum is not a serious condition and generally resolves on its own within a few days without any treatment. However, the nurse should continue to monitor the newborn for signs of jaundice, which can occur due to the breakdown of red blood cells in the swelling.
Correct Answer is A
Explanation
One of the most important principles of effective health education is to involve the target audience in the planning process. By involving the target audience in the planning process, the nurse can gain a better understanding of their needs, priorities, and concerns related to health and wellness. This, in turn, can help the nurse develop education goals that are relevant, engaging, and effective at improving health outcomes.
Asking the formal leadership of a community what the learning needs are, using the expertise of professional nurses who are skilled at assessing needs, or interviewing physicians to determine the highest need based on diagnoses can all be useful strategies for gathering information about community health needs. However, none of these strategies are as effective at identifying the specific needs and priorities of the target audience as asking the target audience directly.
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