A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.
As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

Pain in the abdomen, shoulder, or back.

Respiratory depression, hypotension, absent tendon reflexes.

Severe lower back pain, leg cramps, sweating.

Low potassium or elevated glucose, tachycardia, chest pain.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.

Choice B rationale

Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.

Choice C rationale

Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.

Choice D rationale

Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.

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Correct Answer is B

Explanation

Choice A rationale

Supine positioning can compress the vena cava, leading to decreased venous return, reduced cardiac output, and potential maternal hypotension, which can compromise fetal oxygenation. Alternative positions like lateral or semi-recumbent are generally preferred during labor to optimize blood flow.

Choice B rationale

Assessing anesthesia or pain level every 30 minutes is crucial in the active phase of labor to evaluate the effectiveness of pain management interventions and the client's comfort. This frequent monitoring allows for timely adjustments to the pain management plan based on the client's subjective experience and physiological responses.

Choice C rationale

While assessing vaginal bleeding and the fundus is important in the postpartum period to monitor for uterine involution and hemorrhage, it is not the priority during the active phase of labor. The focus during active labor is on maternal and fetal well-being during the labor process itself.

Choice D rationale

Continuous or intermittent oxygen saturation monitoring may be indicated based on the client's condition and fetal heart rate patterns, but it is not a routine assessment every half hour for all clients in active labor. It is typically reserved for situations of suspected maternal hypoxemia or fetal distress.

A. Ectopic pregnancy. B. Molar pregnancy.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. Symptoms can include unilateral abdominal pain, light to heavy vaginal bleeding, and a positive pregnancy test. An ectopic pregnancy is a serious condition requiring prompt medical attention.

Choice B rationale

Molar pregnancy, also known as gestational trophoblastic disease, is characterized by abnormal growth of trophoblasts, the cells that normally develop into the placenta. It can present with symptoms such as vaginal bleeding (ranging from spotting to heavy bleeding), pelvic pain or pressure, and a uterus that may be larger than expected for the gestational age. The absence of a fetal heartbeat and elevated hCG levels are also characteristic.

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A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

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The nurse is managing care of a primigravida at full term who is in the active phase of labor.What should be included in developing the plan of care for this client?

Correct Answer is B

Explanation

A nurse is caring for a client who is being admitted to the labor and delivery unit.Client reports mild abdominal pain and light vaginal bleeding.Reports last menstrual period was 11 weeks ago.

Correct Answer is ["A","B"]

Explanation

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A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.
As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?