A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

Increased fetal movement

Increased respiratory rate

Increased muscle weakness

Increased urinary output

Answer and Explanation

The Correct Answer is C

The correct answer is choice C, "Increased muscle weakness." The nurse should instruct the client to report increased muscle weakness, as this can indicate toxicity from magnesium sulfate. Increased fetal movement is not an indication of toxicity from magnesium sulfate. Increased respiratory rate is a common side effect of magnesium sulfate and does not require intervention unless it is significantly increased. Increased urinary output is a normal effect of magnesium sulfate and does not require intervention.

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Correct Answer is D

Explanation

The correct answer is choice D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score." components of the Apgar score:

Component	0 Points	1 Point	2 Points
Heart Rate	Absent	<100 bpm	>100 bpm
Respiratory Effort	Absent	Slow, irregular	Good, crying
Muscle Tone	Flaccid	Some flexion	Active motion
Reflex Irritability	No response	Grimace	Vigorous cry
Color	Blue, pale	Body pink, extremities blue	Completely pink

The score for each component is summed up to a maximum score of 10, with 10 indicating the healthiest newborn. The NRP guidelines emphasize that resuscitation efforts should be initiated immediately after delivery, regardless of the Apgar score, thus choice C is wrong.

A. "Move your toddler to his new bed 2 months before the baby comes home." B. "Avoid bringing your toddler to prenatal visits." C. "Require scheduled interactions between the toddler and the baby." D. "Let your toddler see you carrying the baby into the home for the first time."

Correct Answer is C

Explanation

A. "Move your toddler to his new bed 2 months before the baby comes home.": While moving the toddler to a new bed ahead of time may reduce disruption, it does not directly address fostering a relationship between the toddler and the new sibling.

B. "Avoid bringing your toddler to prenatal visits.": This discourages inclusion and may make the toddler feel left out of the excitement and preparations.

C. "Require scheduled interactions between the toddler and the baby.": Establishing structured, predictable interactions ensures the toddler becomes familiar with and accepts the baby as part of their life. These positive, guided interactions can help the toddler develop affection for their sibling and feel included.

D. "Let your toddler see you carrying the baby into the home for the first time.": This approach could make the toddler feel excluded, as it focuses on the baby rather than involving the toddler in the homecoming experience.

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A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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