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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 B

Explanation

Choice B rationale

Informing the anesthesia care provider is the priority action. Ingesting coffee within a few hours before surgery can affect anesthesia management, and the anesthesia team needs to be aware of any potential complications.

Choice A rationale

Starting the IV is important but not the priority in this scenario. The anesthesia care provider needs to be informed first.

Choice C rationale

Contacting the obstetrician is also important but comes after informing the anesthesia care provider.

Choice D rationale

Ensuring preoperative lab results are available is essential, but the first step should be to inform the anesthesia care provider about the coffee intake.

A. Blood pressure: 170/98 mm Hg B. Pain rating: 5/10 with contractions C. Variable decelerations: 20 seconds D. Magnesium sulfate infusion ongoing

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Blood pressure: 170/98 mm Hg: Abnormal. A blood pressure reading of 170/98 mm Hg is high, especially in the context of pregnancy, where it may indicate gestational hypertension or the potential for preeclampsia. This needs to be monitored closely.
Pain rating: 5/10 with contractions: Normal. A pain rating of 5/10 is typical during labor, especially at this stage of dilation (4 cm). Pain management can be adjusted based on the client's preference and progress.
Variable decelerations: 20 seconds: Normal. Occasional variable decelerations (drops in fetal heart rate that last for less than 30 seconds) can occur during labor, often due to umbilical cord compression. As long as the decelerations are brief and not repetitive or severe, they are typically not concerning.
Magnesium sulfate infusion ongoing: Normal. The magnesium sulfate infusion is prescribed to manage potential complications, likely to prevent preterm labor or to prevent seizures in the event of preeclampsia. Its ongoing use is appropriate for this client at this stage.

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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

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.Which action should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse evaluates the client’s progress. Review the findings below and determine if each one is normal or abnormal.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

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.