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.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Use a fingertip to palpate the inguinal canal for a weakening or indentation:
This is a reasonable next step in assessing for undescended testes. Palpating the inguinal canal can help determine if the testes are located in the inguinal area.

B.Measure the size of the scrotal sac for length and width:
While scrotal size can be relevant in some contexts, it may not provide direct information about the presence or absence of the testes. Palpation or other methods are more specific for this purpose.

C. Perform transillumination of the scrotal sac to visualize shadows of the testes:
Transillumination involves shining light through tissues to detect structures. However, in the case of evaluating the presence of testes, palpation is usually a more direct and accurate method.

D. Observe the urethral opening on the surface of the penis when the newborn voids:
This option is unrelated to assessing the presence of testes. Observing the urethral opening is more relevant for assessing the anatomy of the penis.

A. Unilateral lower leg pain. B. Soft, spongy fundus C. Saturating two perineal pads per hour. D. Pulse rate of 56 beats/minute

Correct Answer is D

Explanation

A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.

B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.

C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.

D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.

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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

During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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