The patient has been on IV magnesium sulfate for severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature of 37.3 C, HR 88, RR 9. B/P 140/90, absent deep tendon reflexes, and no ankle clonus. The patient complains, "I am so thirsty and warm," and seems lethargic. The nurse's first action is to:

Call for a STAT magnesium level

Do nothing, this is the expected action of magnesium

Prepare to administer hydralazine

Decrease or Discontinue the magnesium sulfate infusion

Answer and Explanation

The Correct Answer is D

A. Call for a STAT magnesium level. While obtaining a magnesium level is important to confirm magnesium toxicity, the priority action is to stop or reduce the infusion immediately to prevent further toxicity and respiratory depression.

B. Do nothing, this is the expected action of magnesium. Absent deep tendon reflexes, lethargy, and respiratory depression (RR 9) are signs of magnesium toxicity, not expected therapeutic effects. Immediate intervention is necessary to prevent worsening respiratory and cardiac complications.

C. Prepare to administer hydralazine. Hydralazine is used to treat hypertension in preeclampsia, but this patient’s blood pressure is not critically high, and the primary concern is magnesium toxicity, not hypertension. Administering hydralazine would not address the immediate life-threatening issue.

D. Decrease or Discontinue the magnesium sulfate infusion. The first action in magnesium toxicity is to stop or reduce the infusion to prevent further accumulation. If symptoms worsen, calcium gluconate, the antidote for magnesium toxicity, may be administered to reverse its effects, especially if respiratory depression progresses.

Nursing Test Bank

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Correct Answer is A

Explanation

A. "I don't need to see the doctor for another year when I will come back for follow-up." This statement is incorrect because close follow-up is essential after a molar pregnancy to monitor for gestational trophoblastic disease (GTD) or choriocarcinoma. Regular hCG level monitoring is required weekly until levels are undetectable, then monthly for at least 6–12 months. Delaying follow-up for a year could lead to missed complications.

B. "I will use contraception for the next year." This statement is correct. Pregnancy should be avoided for at least one year after a molar pregnancy to ensure accurate monitoring of hCG levels. A rising hCG level could indicate malignant transformation rather than a new pregnancy.

C. "I need to be monitored for choriocarcinoma during the next year." This statement is correct. Choriocarcinoma is a potential complication of molar pregnancy, and early detection through serial hCG monitoring is crucial. Any persistent or rising hCG levels may indicate malignancy requiring chemotherapy.

D. "I am so sad that I lost this baby." This statement is understandable. A molar pregnancy is an emotionally distressing event, and feelings of grief and loss are valid. Emotional support, counseling, or support groups may be beneficial for the patient’s mental well-being.

A. The cervix is effacing and dilated to 2 cm B. Irregular, mild uterine contractions are occurring every 15-30 minutes C. Estriol is not found in maternal saliva D. Fetal fibronectin is present in vaginal secretions

Correct Answer is A

Explanation

A. The cervix is effacing and dilated to 2 cm. Cervical changes, including effacement and dilation, are the most definitive signs of preterm labor. Uterine contractions alone do not confirm preterm labor unless they result in cervical dilation, indicating that labor is progressing.

B. Irregular, mild uterine contractions are occurring every 15-30 minutes. Irregular contractions, known as Braxton Hicks contractions, can be common in pregnancy and do not necessarily indicate preterm labor. True preterm labor involves regular contractions that lead to cervical changes.

C. Estriol is not found in maternal saliva. The absence of estriol in maternal saliva does not confirm or rule out preterm labor. Salivary estriol testing is not a widely used or reliable diagnostic tool for determining the onset of preterm labor.

D. Fetal fibronectin is present in vaginal secretion. Fetal fibronectin (fFN) is a protein found in vaginal secretions between 22-34 weeks of pregnancy and can indicate a risk of preterm labor, but its presence alone does not confirm that labor is actively occurring. A positive fFN test means the patient may be at increased risk for preterm labor, but cervical changes remain the best indicator of actual labor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is being discharged from the hospital after the evacuation of a molar pregnancy. The nurse recognizes that additional discharge teaching is required when the patient makes which statement?

Correct Answer is A

Explanation

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. Which finding is most indicative that preterm labor is occurring?

Correct Answer is A

Explanation

An emergency shoulder dystocia delivery occurred that requires the nurse to apply suprapubic pressure. What is the rationale for this action?

A woman at 39 weeks gestation with a history of preeclampsia is admitted to the labor and delivery. She suddenly experiences increased contraction frequency of every 1 to 2 minutes, dark red bleeding and a tense, very painful abdomen. The nurse suspects the onset of:

A client at 35 weeks' gestation is admitted with a partial abruptio placenta and a Category III fetal heart rate tracing with minimal variability and a prolonged deceleration. The nurse anticipates a plan of care for this client that includes most importantly:

A woman who is 26 weeks pregnant has just found out that she has gestational diabetes. Which of the following therapies will most likely be ordered first for this patient?

A patient has just spontaneously ruptured her membranes. Which of the following factors makes her especially high risk for having a prolapsed cord? Select all that apply.

For a woman at 42 weeks gestation, which finding would require more assessment by the nurse?

When working with a woman who has just experienced a fetal demise you should offer supportive care, give her the opportunity to grieve, and provide for a chaplain to come in if the patient wants one. You know that the Chaplain is non-denominational and can also provide comforting words.

Preconception counseling is critical to the outcome of a pregnancy for a patient with diabetes because poor glycemic control before and during early pregnancy is associated with: