The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?

Insert a Foley catheter with a urimeter to monitor hourly output

Have calcium gluconate immediately available

Provide a quiet environment with subdued lighting.

Assess deep tendon reflexes (DTRS) every 4 hours.

Answer and Explanation

The Correct Answer is B

A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.

B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.

C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.

D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.

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Correct Answer is A

Explanation

A. Cries vigorously when stimulated:
Explanation: Vigorous crying is a positive sign in a newborn. It indicates that the baby is responsive, breathing effectively, and is capable of establishing the necessary air exchange.

B. A positive Babinski reflex:
Explanation: The Babinski reflex is a normal reflex in infants where the toes spread out when the sole of the foot is stimulated. While it is a normal reflex in newborns, it might not necessarily indicate the immediate transition to extrauterine life.

C. Heart rate of 220 beats/minute:
Explanation: A heart rate of 220 beats per minute in a newborn is higher than the normal range. It could be a sign of tachycardia, and this finding might require further evaluation by healthcare providers.

D. Flexion of all four extremities:
Explanation: Flexion of extremities is a normal response in a newborn, but it might not specifically indicate successful transition. It's a common response seen in healthy newborns.

A. Describe genetic testing protocols B. Discontinue the methadone right away C. Sign up for group therapy sessions D. Start a prenatal care plan as soon as possible

Correct Answer is D

Explanation

A. Describe genetic testing protocols: While genetic testing may be part of prenatal care, it's not the primary concern for a pregnant woman addicted to heroin. The focus should be on managing the addiction and promoting a healthy pregnancy.

B. Discontinue the methadone right away: Abruptly stopping methadone, or any opioid replacement therapy, can lead to withdrawal symptoms, which can be harmful to both the mother and the fetus. It's crucial for pregnant individuals on methadone to work closely with their healthcare provider to manage the transition.

C. Sign up for group therapy sessions: Group therapy can be a supportive intervention for individuals dealing with addiction, but it should be part of a comprehensive treatment plan that includes medical management.

D. Start a prenatal care plan as soon as possible: This is the most appropriate choice. Prenatal care is crucial for monitoring the health of both the mother and the baby. Starting early allows healthcare providers to address any potential issues and provide necessary support. This includes managing the mother's opioid addiction through medications like methadone, which can be administered under close medical supervision during pregnancy.

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The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is A

Explanation

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy? Which information should the nurse provide?

Correct Answer is D

Explanation

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