A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

Hypertension

Hypoglycemia

Respiratory rate 16/min

Urine output 20 mL/hr

Answer and Explanation

The Correct Answer is D

A) Hypertension is not typically an adverse reaction to magnesium sulfate; this medication is actually used to lower high blood pressure in preeclampsia.

B) Hypoglycemia is also not a common adverse reaction to magnesium sulfate. This medication does not typically affect blood sugar levels.

C) A respiratory rate of 16/min is within normal limits and is not indicative of an adverse reaction to magnesium sulfate, which can cause respiratory depression if it does affect breathing.

D) Urine output of 20 mL/hr is a concerning sign and can indicate nephrotoxicity or acute kidney injury, which are possible adverse reactions to magnesium sulfate, especially in the context of preeclampsia where kidney function must be closely monitored.

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Correct Answer is C

Explanation

Pregnant clients with HIV require comprehensive care during pregnancy, delivery, and postpartum periods to prevent transmission of HIV to the newborn. Bathing the newborn before initiating skin-to-skin contact is a recommended action to reduce the risk of HIV transmission from mother to child. This practice helps to remove any maternal blood or other bodily ﬂuids from the newborn's skin, which may contain the virus. Therefore, the nurse should instruct the client to bathe the newborn before initiating skin-to-skin contact.

Antiretroviral medications are usually continued throughout pregnancy and during labor and delivery to decrease the risk of transmission to the newborn. Therefore, the nurse should not instruct the client to stop taking antiretroviral medications at 32 weeks of gestation, as mentioned in option a.

Fetal scalp electrode is a device that ataches to the baby's scalp to monitor the fetal heart rate. This device can cause small cuts or abrasions on the baby's scalp, which may increase the risk of HIV transmission.

Therefore, its use should be avoided in clients with HIV. Therefore, option b is not a recommended action.

Administering pneumococcal immunization to the newborn within 4 hours following birth is not a recommended action in the plan of care for a client who is pregnant and has HIV. Pneumococcal immunization is not indicated for newborns immediately after birth. Therefore, option d is not a recommended action.

A. Oﬀer to take the newborn to the nursery to finish his feeding B. Insist that the mother pick up the newborn to feed him C. Demonstrate how to hold the newborn and allow the client to practice D. Persuade the client to breastfeed the newborn to promote bonding

Correct Answer is C

Explanation

This option respects the mother's wishes of not wanting to hold the newborn while also allowing the nurse to provide education on safe and appropriate feeding positions. It also gives the mother the opportunity to learn and practice holding the newborn in a safe way.

Option a, oﬀering to take the newborn to the nursery, may not be necessary as the mother is already oﬀering the baby a botle.

Option b, insisting that the mother pick up the newborn, would not be respectful of her wishes and could potentially damage the trust and rapport between the mother and nurse.

Option d, persuading the client to breastfeed, may not be appropriate or feasible in this situation as it may not be the mother's preferred feeding method and may not address the immediate concern of the newborn being too tired to be held.

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A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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