A nurse is performing a neurological examination on a client as part of a complete physical assessment.
The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

 

Choice A rationale:

Give the client protamine if signs of magnesium sulfate toxicity occur. Protamine is not the antidote for magnesium sulfate toxicity. Calcium gluconate or calcium chloride is used to counteract the effects of magnesium sulfate toxicity by antagonizing the action of magnesium on the neuromuscular junction and the heart.

Choice B rationale:

Monitor the FHR via Doppler every 30 min. While fetal heart rate (FHR) monitoring is important during magnesium sulfate infusion due to the risk of fetal distress, using Doppler every 30 minutes may not provide continuous and accurate monitoring. Continuous electronic fetal monitoring is the standard of care in this situation.

Choice C rationale:

Restrict the client's total fluid intake to 250 mL/hr. Magnesium sulfate is excreted by the kidneys, so maintaining adequate urine output is crucial to prevent magnesium toxicity. Restricting fluid intake to 250 mL/hr would likely reduce urine output, leading to an increased risk of magnesium sulfate accumulation in the body, which could be harmful.

Choice D rationale:

Measure the client's urine output every hour. Monitoring urine output is essential during magnesium sulfate infusion as it helps assess renal function and magnesium excretion. Adequate urine output (at least 30 mL/hr) is necessary to prevent magnesium toxicity. Therefore, measuring the client's urine output every hour is a critical nursing intervention to ensure the safety of the client.

Choice A rationale:

Spotting is a common finding in placenta previa. It occurs due to the abnormal implantation of the placenta over or near the cervical os, leading to vaginal bleeding. This bleeding can range from mild spotting to severe hemorrhage and is a significant sign of placenta previa.

Choice B rationale:

Nausea is not a specific sign of placenta previa. Nausea and vomiting are common symptoms during early pregnancy but are not directly related to placenta previa.

Choice C rationale:

A board-like abdomen is a sign of peritonitis or an acute abdomen, which is not associated with placenta previa. This finding suggests intra-abdominal inflammation and is unrelated to the condition in question.

Choice D rationale:

Delayed menses is a common sign of pregnancy, but it does not specifically indicate placenta previa. Placenta previa is characterized by vaginal bleeding, which is not synonymous with a delay in menstrual periods.