A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia.
Which of the following findings should the nurse report to the provider?

Headache for 30 min

Fetal heart rate 158/min

Respirations 16/min

Urinary output 40 mL in 2 hr

Answer and Explanation

The Correct Answer is D

Rationale:

A. Headache can be a common side effect of magnesium sulfate but is usually not concerning unless severe or persistent.

B. A fetal heart rate of 158/min is within the normal range for a fetus and is not typically associated with magnesium sulfate administration.

C. Respirations of 16/min are within the normal range and are not typically associated with magnesium sulfate administration.

D. A urinary output of 40 mL in 2 hours is significantly reduced and may indicate magnesium toxicity or impaired renal function, which should be reported to the provider for further

evaluation and management.

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Correct Answer is A

Explanation

A. "If suspicion of abuse exists then reporting is mandatory."

Rationale:

A. "If suspicion of abuse exists then reporting is mandatory.": Reporting suspected child abuse is mandatory for healthcare workers when there is a reasonable suspicion or belief that a child is being abused or neglected. This is to ensure the safety and well-being of the child.

B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it.": Regardless of the abuser's commitment to stop, healthcare workers are still required to report suspected abuse.

C. "Evidence must exist prior to reporting.": While evidence can strengthen a case, suspicion alone is sufficient to trigger the mandatory reporting of child abuse.

D. "I don't want to defame someone if the report is false.": Reporting suspected abuse is a legal obligation, and defaming someone is not the purpose of reporting. Authorities are responsible for investigating the validity of the report.

A. Administer oral morphine. B. Swaddle the newborn. C. Administer naloxone for NAS scores greater than 24. D. Encourage the birthing parent to breastfeed. E. Continue NAS scoring as prescribed

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

Explanation

A. Administering oral morphine is anticipated because it is used to manage withdrawal symptoms in newborns with Neonatal Abstinence Syndrome (NAS..
B. Swaddling is a non-pharmacological intervention that can provide comfort and reduce overstimulation.
C. Administering naloxone is not typically the first line of treatment for NAS and is used in cases of acute opioid overdose, which is not indicated by the information provided.
D. Encouraging the birthing parent to breastfeed may not be appropriate due to the presence of heroin in the system, which can be transmitted to the newborn through breast milk.
E. Continuing NAS scoring is essential to monitor the newborn's condition and response to treatment.

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A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia.Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia.
Which of the following findings should the nurse report to the provider?