Choice A rationale:

Calcium gluconate is the antidote for magnesium sulfate toxicity. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia, but it can lead to respiratory depression and toxicity when levels become too high. Administering calcium gluconate helps counteract the effects of magnesium toxicity by competing for binding sites and restoring neuromuscular function. This is the appropriate treatment to address the client's symptoms of respiratory depression, which are suggestive of magnesium sulfate toxicity.

Choice B rationale:

Flumazenil is not the correct choice in this situation. Flumazenil is a medication used to reverse the effects of benzodiazepine overdose, not magnesium sulfate toxicity. It does not have any impact on magnesium levels or their associated toxic effects.

Choice C rationale:

Naloxone is used to reverse the effects of opioids, such as morphine or fentanyl. It is not indicated for magnesium sulfate toxicity. Administering naloxone would not address the client's symptoms or the underlying cause of respiratory depressionzz.

Choice D rationale:

Protamine sulfate is an antidote used to reverse the anticoagulant effects of heparin, not magnesium sulfate. It is not effective in treating magnesium sulfate toxicity. Administering protamine sulfate would not be the appropriate intervention for this situation.

Choice A rationale:

To prevent thrombophlebitis in a postpartum client following a cesarean birth, it is important to promote good circulation and prevent stasis of blood in the lower extremities. Placing pillows under the client's knees while she is resting in bed helps elevate the legs slightly and promotes better venous return, reducing the risk of thrombophlebitis. This position facilitates improved circulation and is a recommended practice.

Choice B rationale:

Applying hot moist soaks to the client's lower legs is not a recommended intervention to prevent thrombophlebitis. In fact, heat can increase inflammation and may worsen the condition. This option would not contribute to the client's plan of care for thrombophlebitis prevention.

Choice C rationale:

Assisting the client to ambulate in the hallway is a good practice to prevent thrombophlebitis, but it may not be suitable for a client who is only 1 day postpartum following a cesarean birth. Early ambulation is encouraged but should be done gradually and at the client's own pace to avoid undue stress on the incision site. Placing pillows under the knees while resting in bed is a more appropriate initial intervention.

Choice D rationale:

Keeping the client on bed rest is not the best option for preventing thrombophlebitis in a postpartum client. Immobility can increase the risk of stasis and clot formation. Promoting circulation, such as elevating the legs with pillows, is a more effective strategy to reduce the risk of thrombophlebitis.

Choice A rationale:

Blotting the perineal area dry after voiding is an important part of perineal care. Moisture can contribute to perineal infection, so it is essential to keep the area dry. This practice helps prevent the growth of bacteria and reduces the risk of infection.

Choice D rationale:

Cleaning the perineal area from front to back is crucial in reducing the risk of perineal infection. This method helps prevent the transfer of bacteria from the anal area to the perineum and vaginal area, reducing the risk of infection.

Choice E rationale:

Performing hand hygiene before and after voiding is an important aspect of perineal care and infection prevention. Proper hand hygiene helps prevent the transfer of bacteria from the hands to the perineal area and vice versa, reducing the risk of infection.

Choice B rationale:

Applying ice packs to the perineal area several times daily is not a recommended practice for reducing the risk of perineal infection. While ice packs can provide pain relief and reduce swelling, they should not be applied excessively, as prolonged exposure to cold can compromise blood flow and potentially increase the risk of tissue damage or infection.

Choice C rationale:

Sitting on an inflatable donut to protect the perineum is not a recommended practice for reducing the risk of perineal infection. Inflatable donuts can increase pressure on the perineal area, potentially causing discomfort and impairing blood flow. Proper hygiene and keeping the area clean and dry are more effective strategies for infection prevention. .

A nurse is reinforcing nutritional teaching with a client who is at 8 weeks of gestation. Which of the following statements should the nurse include? The correct answer is choice B: "You should increase your folic acid intake during your pregnancy.”.

Choice A rationale:

"You should stop taking your prenatal vitamin if you experience nausea.”. This statement is incorrect. Nausea is a common symptom during pregnancy, especially during the first trimester. However, discontinuing prenatal vitamins is not recommended. It's essential to continue taking them to ensure the mother and baby receive adequate nutrients. Prenatal vitamins are designed to provide essential vitamins and minerals that are crucial for the baby's development. Discontinuing them due to nausea could lead to nutrient deficiencies.

Choice C rationale:

"You should limit your iron intake during your first trimester.”. This statement is incorrect. Iron intake should not be limited during the first trimester. Iron is an essential mineral during pregnancy, as the mother's blood volume increases, and iron is required to make more red blood cells to carry oxygen to the baby. Iron deficiency can lead to anemia, which can be harmful to both the mother and the baby. Therefore, iron intake is typically increased during pregnancy to meet the increased demand.

Choice D rationale:

"You should increase your daily calorie intake by 750 calories.”. This statement is not entirely accurate. While it's true that calorie needs increase during pregnancy, the recommended additional calorie intake is generally around 300-500 calories per day, not 750. The exact number can vary from person to person, depending on their pre-pregnancy weight and activity level. Consuming too many extra calories can lead to excessive weight gain, which can have negative consequences for both the mother and the baby. It's important to focus on the quality of calories consumed and ensure they come from nutrient-dense foods.

A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client? The correct answer is choice D: "You will need an immunization following delivery.”.

Choice A rationale:

"You had the rubella infection as a child.”. This statement is incorrect. A negative rubella titer indicates that the client is not immune to rubella. Even if the client had the infection as a child, it does not guarantee immunity for life. Immunity can wane over time, and some individuals may not have developed sufficient immunity after a natural infection.

Choice B rationale:

"I will administer the rubella immunization to you today.”. This statement is not recommended. Rubella vaccination is a live attenuated vaccine, and it is generally contraindicated during pregnancy due to the theoretical risk of transmission to the fetus. Rubella vaccination is usually recommended postpartum if the woman is not immune. The nurse should not administer the vaccine during pregnancy.

Choice C rationale:

"You are immune to rubella.”. This statement is incorrect. A negative rubella titer clearly indicates that the client is not immune to rubella. It's crucial for healthcare providers to provide accurate information to the client and ensure that appropriate immunization is administered postpartum to protect both the mother and the newborn.

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions? The correct answer is choice B: Placenta previa.

Choice A rationale:

"Abruptio placentae.”. This choice is incorrect. Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which can result in painful and dark red vaginal bleeding. It is associated with abdominal pain and fetal distress. In this case, the bleeding is described as painless and bright red, which is more indicative of placenta previa.

Choice C rationale:

"Preterm labor.”. This choice is incorrect. Preterm labor involves regular uterine contractions that result in cervical changes before 37 weeks of gestation. Painless, bright red vaginal bleeding is not typically associated with preterm labor. It is more often seen in placenta previa.

Choice D rationale:

"Threatened abortion.”. This choice is incorrect. Threatened abortion refers to vaginal bleeding in the first half of pregnancy, typically accompanied by mild uterine cramping. The bleeding is often associated with the possibility of miscarriage. However, the scenario described in the question occurs at 36 weeks of gestation, which is well into the third trimester and not within the typical timeframe for a threatened abortion.

Choice A rationale:

Maternal hypertension is the most common risk factor for placental abruption. Placental abruption is a serious condition where the placenta partially or completely separates from the uterine wall before the baby is born. This separation can lead to significant bleeding, which is a medical emergency. Hypertension, also known as high blood pressure, can cause damage to the blood vessels in the placenta, making it more likely for placental abruption to occur. High blood pressure can lead to decreased blood flow to the placenta, increasing the risk of separation.

Choice B rationale:

Maternal battering, while a concerning issue during pregnancy, is not the most common risk factor for placental abruption. Placental abruption is primarily associated with maternal medical conditions and factors that affect the uterine environment.

Choice C rationale:

Maternal cigarette smoking can have adverse effects on pregnancy, but it is not the most common risk factor for placental abruption. Smoking is more commonly associated with other complications such as low birth weight and preterm birth.

Choice D rationale:

Maternal cocaine use is a risk factor for placental abruption, but it is not the most common one. Cocaine can constrict blood vessels and reduce blood flow to the placenta, increasing the risk of abruption. However, hypertension remains the most prevalent risk factor.

Choice A rationale:

"Tell me more about your concerns" is an appropriate therapeutic response by the nurse. It encourages the client to express her worries and fears about the pelvic examination. Open-ended questions like this one allow the nurse to better understand the client's specific concerns, which can help in addressing them effectively.

Choice B rationale:

"All you need to do is relax during the exam" may come across as dismissive and may not address the client's anxiety effectively. It's important to acknowledge the client's feelings and offer support rather than making the situation seem overly simplistic.

Choice C rationale:

"Don't worry. I will stay in there with you for the exam" might make the client feel like she has no control over the situation and can be invasive. While offering support is important, it's essential to respect the client's autonomy and provide emotional support through active listening and communication.

Choice D rationale:

"A pelvic exam is required if you want birth control pills" is not an appropriate response to the client's anxiety about the pelvic exam. This response does not address the client's concerns and may not provide the necessary emotional support or information she needs.

Choice A rationale:

Administering the measles, mumps, rubella (MMR) vaccine two weeks before attempting pregnancy again is not the correct timing. It is important to provide the MMR vaccine postpartum before the client is discharged from the hospital after giving birth. This timing is appropriate to protect the woman from rubella and to avoid vaccinating during pregnancy.

Choice B rationale:

The correct timing for the MMR vaccine is prior to discharge from the hospital after giving birth. This approach ensures that the woman is protected against rubella before leaving the hospital and potentially becoming pregnant again. It is crucial to avoid vaccinating during pregnancy because the MMR vaccine contains live attenuated viruses.

Choice C rationale:

Administering the MMR vaccine prior to giving birth is not the recommended timing. Vaccination should be done postpartum to avoid any potential risks to the developing fetus.

Choice D rationale:

Administering the MMR vaccine when the client does not desire future pregnancies is not the most appropriate option. The vaccine should be given postpartum to protect the woman and any future pregnancies from rubella. It is important to provide vaccination recommendations based on evidence-based guidelines and the client's specific situation.

Choice A rationale:

To calculate the amount of vitamin K (1 mg) to administer, you need to use the given concentration (1 mg/0.5 mL). This means that 1 mg is present in every 0.5 mL of the solution. To determine how many milliliters (mL) you should administer to get 1 mg, you can set up a proportion: 1 mg / X mL = 1 mg / 0.5 mL Cross-multiply and solve for X: X = (1 mg * 0.5 mL) / 1 mg X = 0.5 mL Therefore, the nurse should administer 0.5 mL, which can be rounded to 2.0 mL to the nearest tenth of a milliliter. Now, let's move on to the next question.