A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

The client is carrying more than one fetus.

The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor.

An excessive amount of amniotic fluid is present.

There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid.

Answer and Explanation

The Correct Answer is C

Choice A reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible cause of it. Polyhydramnios is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can occur in multiple pregnancies, as the fetuses produce more urine and fluid than a single fetus.

Choice B reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible complication of it. Polyhydramnios can cause fetal anomalies, such as esophageal atresia, anencephaly, or neural tube defects, which impair the swallowing or absorption of the amniotic fluid. Polyhydramnios can also cause fetal growth restriction or distress, as the excess fluid can compress the umbilical cord or the placenta, and reduce the blood flow and oxygen delivery to the fetus.

Choice C reason: This statement is correct, as it is the definition of polyhydramnios, which is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can be diagnosed by ultrasound, and it can cause maternal and fetal complications, such as preterm labor, premature rupture of membranes, placental abruption, or cord prolapse.

Choice D reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a marker of fetal anomalies. Alpha-fetoprotein (AFP) is a protein that is produced by the fetus, and it can be measured in the maternal serum or the amniotic fluid. An elevated level of AFP in the amniotic fluid can indicate fetal anomalies, such as neural tube defects, abdominal wall defects, or renal anomalies, which can cause polyhydramnios.

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Correct Answer is C

Explanation

Choice A reason: To call for an immediate magnesium sulfate level is not the immediate action that the nurse should take, as it is a diagnostic test that requires a blood sample and a laboratory analysis, which can take time and delay the treatment. The nurse should first stop the infusion and notify the provider, as the client is showing signs of magnesium sulfate toxicity, which is a life-threatening condition that can cause respiratory depression, cardiac arrest, or coma.

Choice B reason: To prepare to administer hydralazine is not the immediate action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the blood pressure and the fetal status. Hydralazine is an antihypertensive drug that lowers the blood pressure and prevents the complications of severe preeclampsia, such as eclampsia, stroke, or organ damage. However, the client's blood pressure is not very high and is not the main problem at the moment.

Choice C reason: To discontinue the magnesium sulfate infusion is the immediate action that the nurse should take, as it is the first and most important intervention that can reverse the effects of magnesium sulfate and restore the neuromuscular function and the respiratory rate. Magnesium sulfate is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, but it can also cause toxicity if the dose is too high or the infusion is too fast.

Choice D reason: To administer oxygen is not the immediate action that the nurse should take, as it is a supportive intervention that improves the oxygen delivery to the tissues and organs, but does not address the underlying cause of the respiratory depression, which is the magnesium sulfate toxicity. The nurse should administer oxygen only after stopping the infusion and assessing the oxygen saturation and the respiratory status.

Correct Answer is ["117"]

Explanation

The correct answer is 117 mL/hr.

To calculate the IV rate, the nurse should use the following formula:

IV rate (mL/hr) = (Volume to be infused (mL) / Time of infusion (hr)) x Drop factor (gtt/mL)

In this case, the volume to be infused is 350 mL, the time of infusion is 3 hr, and the drop factor is 1 gtt/mL (assuming the IV pump is calibrated in mL/hr). Therefore, the formula becomes:

IV rate (mL/hr) = (350 mL / 3 hr) x 1 gtt/mL

IV rate (mL/hr) = 116.67 mL/hr

The nurse should round the answer to the nearest whole number, which is 117 mL/hr.

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A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

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Correct Answer is C

Explanation

A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number)

Correct Answer is ["117"]

Explanation

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