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The nurse reviews the assessment findings along with the healthcare provider's prescriptions.
Which immediate intervention(s) would the nurse initiate? Select all that apply.

Increase IV fluids.

Obtain blood pressure.

Stop infusion of magnesium.

Administer oxygen.

Obtain serum magnesium level.

Prepare for a cesarean delivery.

Administer calcium gluconate.

Prepare to prevent respiratory or cardiac arrest.

Answer and Explanation

Correct Answer : A,C,D,E,G

Choice A rationale

Increasing IV fluids is a critical intervention to maintain maternal hemodynamic stability and prevent complications related to fluid imbalance. It helps support blood pressure and overall fluid status during labor and delivery.

Choice B rationale

While obtaining blood pressure is important for monitoring maternal status, it is not an immediate intervention compared to others listed. Blood pressure monitoring is part of routine assessment but not an emergency action.

Choice C rationale

Stopping the infusion of magnesium is essential if there are signs of magnesium toxicity or adverse effects. Magnesium can impact respiratory and cardiac function, so stopping the infusion is a priority.

Choice D rationale

Administering oxygen is an immediate intervention to ensure adequate oxygenation for both the mother and the fetus. It is crucial during labor and delivery to prevent hypoxia and related complications.

Choice E rationale

Obtaining serum magnesium level is necessary to assess for magnesium toxicity and guide further interventions. It provides important information on the mother's magnesium status and helps in making clinical decisions.

Choice F rationale

Preparing for a cesarean delivery is not an immediate intervention unless there are specific indications for surgical delivery. It should be based on clinical findings and maternal-fetal status.

Choice G rationale

Administering calcium gluconate is the antidote for magnesium toxicity and is an immediate intervention if signs of toxicity are present. It helps counteract the effects of excessive magnesium.

Choice H rationale

Preparing to prevent respiratory or cardiac arrest is a critical intervention in severe cases of magnesium toxicity, but it should be part of a broader emergency management plan rather than an immediate action. .

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale

Gravidity refers to the total number of times a woman has been pregnant, regardless of the outcome. This client has had one full-term infant, one premature infant, and one miscarriage, plus the current pregnancy, making a total of four pregnancies.

Choice B rationale

Gravidity is not determined by the number of live births. This client has had more than three pregnancies, so Gravida 3 is incorrect.

Choice C rationale

Gravidity does not count the number of live births and miscarriages separately. It counts the total number of pregnancies, making Gravida 5 incorrect in this context.

Choice D rationale

Gravida 2 would only apply if the client had been pregnant twice, which is not the case here.

A. Increase the infusion rate to 4 g/hour if contractions persist. B. Assess the client’s deep tendon reflexes and respiratory rate before administration. C. Stop the infusion if variable decelerations are noted. D. Administer an antihypertensive medication prior to starting magnesium sulfate.

Correct Answer is B

Explanation

Choice A rationale: Increasing the infusion rate of magnesium sulfate without medical approval is not appropriate. The prescribed rate should be followed unless the provider orders a change.

Choice B rationale: Assessing the client’s deep tendon reflexes and respiratory rate before administering magnesium sulfate is crucial. Magnesium sulfate can depress the central nervous system and respiratory function, so baseline assessments are necessary to identify any adverse effects early.

Choice C rationale: Stopping the infusion for variable decelerations is not the initial step. Variable decelerations may need to be addressed, but it is not the priority action before starting magnesium sulfate.

Choice D rationale: Administering an antihypertensive medication is important if the blood pressure remains elevated, but it is not specified as required before starting magnesium sulfate.

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The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full-term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage.Which is this client's gravidity?

Correct Answer is A

Explanation

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse prepares to initiate magnesium sulfate therapy for the client. What is the priority nursing action?

Correct Answer is B

Explanation

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The nurse reviews the assessment findings along with the healthcare provider's prescriptions.
Which immediate intervention(s) would the nurse initiate? Select all that apply.