A nurse is assisting with the care of a client who is at 34 weeks of gestation and received a dose of nifedipine 2 hr ago. For which of the following therapeutic effects should the nurse monitor?

An increase in platelet count

A decrease in blood pressure

A decrease in FHR

An increase in urinary output

Answer and Explanation

The Correct Answer is B

A.   Nifedipine does not directly affect platelet count.
B.   Nifedipine is a calcium channel blocker used to lower blood pressure. Monitoring for a decrease in blood pressure is essential.
C.   Nifedipine does not typically cause a significant decrease in fetal heart rate (FHR).
D.   While nifedipine may impact urinary output indirectly through blood pressure regulation, it is not the primary therapeutic effect to monitor.

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Correct Answer is C

Explanation

Choice A is incorrect because security tags are a vital part of hospital security protocols to prevent newborn abduction, and they should be worn at all times, even when the baby is in the room with the parent.

Choice B is incorrect as while it is important to have a list of authorized individuals, it does not directly prevent abduction; the staff still needs to verify each person's identity before allowing them to take the baby.

Choice C is correct because it demonstrates the client's understanding that all hospital staff should have proper identification, especially when they are involved in newborn care, which is a critical security measure.

Choice D is incorrect because having only one identification band is insufficient; multiple forms of identification for both the parent and the newborn are necessary to ensure the baby's safety and prevent any mix-up or abduction.

A. Hyporeflexia B. Tachypnea C. Polyuria D. Agitation

Correct Answer is A

Explanation

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

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A nurse is assisting with the care of a client who is at 34 weeks of gestation and received a dose of nifedipine 2 hr ago. For which of the following therapeutic effects should the nurse monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about the prevention of newborn abduction with a client who gave birth 8 hr ago. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy. For which of the following adverse effects should the nurse monitor and report to the provider?

Correct Answer is A

Explanation

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