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

Assess deep tendon reflexes (DTRS) every 4 hours.

Provide a quiet environment with subdued lighting.

Have calcium gluconate immediately available.

Insert an indwelling urinary catheter with a urimeter to monitor hourly output.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Assess deep tendon reflexes (DTRs) every 4 hours: Monitoring DTRs is essential to detect early signs of magnesium toxicity, but the frequency of assessment alone does not immediately prevent life-threatening complications.

B. Provide a quiet environment with subdued lighting: A calm environment helps reduce maternal stress and may support labor progression, but it does not address the primary safety concern associated with magnesium sulfate therapy.

C. Have calcium gluconate immediately available: Calcium gluconate is the antidote for magnesium sulfate toxicity. Having it readily available is the highest priority because magnesium toxicity can rapidly depress neuromuscular and respiratory function, requiring immediate intervention.

D. Insert an indwelling urinary catheter with a urimeter to monitor hourly output: Monitoring urine output is important to assess renal function and magnesium excretion, but immediate availability of the antidote takes precedence in preventing life-threatening complications.

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Correct Answer is B

Explanation

Rationale:

A. The mother reports that she has no questions about the care of the harness: Verbalizing no questions does not guarantee understanding or ability to perform proper care. Effective teaching requires demonstration and return demonstration to confirm competence.

B. The nurse observes the mother removing and replacing the Pavlik harness: Observing the mother correctly remove and replace the harness demonstrates that she has learned and can safely manage the device, indicating that discharge teaching was effective.

C. The nurse demonstrates removing the harness and the mother watches closely: Watching the nurse demonstrates the process but does not confirm that the mother can perform the task independently, so it is not a reliable indicator of teaching effectiveness.

D. The mother describes problems that may occur while using the harness: Understanding potential problems is important, but describing them verbally does not confirm that the mother can safely apply and remove the harness, which is essential for proper care.

A. Interest in enrolling in breast feeding classes. B. Herbal supplements the mother is taking. C. Types of foods the mother is eating. D. Length of time the infant nurses at each breast.

Correct Answer is D

Explanation

Rationale:

A. Interest in enrolling in breastfeeding classes: While breastfeeding education is helpful, it does not directly address the immediate concern of poor weight gain in the infant.

B. Herbal supplements the mother is taking: Herbal supplements may affect milk production or infant tolerance in some cases, but they are less likely to be the primary factor when the infant is feeding frequently and producing an adequate number of wet diapers.

C. Types of foods the mother is eating: Maternal diet generally does not significantly impact breast milk quantity or quality in healthy, well-nourished women. While important for overall health, it is not the most critical factor to assess here.

D. Length of time the infant nurses at each breast: Assessing how long the infant feeds at each breast provides crucial information about milk transfer and effectiveness of breastfeeding. Despite frequent nursing and normal diaper output, inadequate time at the breast may explain why the infant has not regained birth weight.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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