A client in preterm labor has had an infusion of magnesium sulfate running for 8 hours.
Current assessment findings are respirations of 14 breaths/minute, a urine output of 25 mL/hr, deep tendon reflexes of 1+, and a serum magnesium level of 8 mEq/L (4 mmol/L). Based on these assessment findings, which conclusion should the nurse reach?

These findings are within normal limits and require routine follow-up.

All findings are outside of the acceptable range and should be reported to the healthcare provider immediately.

The primary IV fluids should be increased to assist in increasing the urinary output.

The findings indicate potential toxicity to the magnesium sulfate and close follow-up is indicated.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.

Choice B rationale

Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.

Choice C rationale

Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.

Choice D rationale

The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.

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Correct Answer is A

Explanation

Choice A rationale

Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.

Choice B rationale

Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.

Choice C rationale

Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.

Choice D rationale

Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.

A. Iron. B. Calcium. C. Vitamin D. D. Folic acid. E. Folic acid.

Correct Answer is D

Explanation

Choice A rationale

Iron is essential for preventing anemia, particularly in pregnant women, but it does not prevent neural tube defects like anencephaly. Iron supports overall maternal and fetal health but is not specific to preventing congenital anomalies.

Choice B rationale

Calcium is crucial for fetal bone development and maternal bone health, but it does not play a role in preventing anencephaly. Adequate calcium intake is important during pregnancy but is not linked to neural tube defect prevention.

Choice C rationale

Vitamin D is important for bone health and immune function but does not prevent neural tube defects. Sufficient vitamin D levels are necessary for the mother's and baby's health but are not related to anencephaly prevention.

Choice D rationale

Folic acid is the correct choice as it has been shown to prevent neural tube defects, including anencephaly and spina bifida. It is recommended that women of childbearing age take folic acid supplements before conception and during early pregnancy to reduce the risk of these congenital anomalies.

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Naxlex Comprehensive Predictor Exams

A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

Correct Answer is A

Explanation

The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

Correct Answer is D

Explanation

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide?

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

During the admission process of a school-age child, the child states, "I'm going to have an operation.”. Which response is best for the nurse to provide to this child?

A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

The nurse is caring for a child with a unilateral long-leg cast applied for the correction of clubfoot. Which action is most important for the nurse to perform?

The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?