A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?

Bowel sounds

Respiratory rate

Temperature

Fetal heart rate (FHR)

Answer and Explanation

The Correct Answer is B

Choice A Reason:

While assessing bowel sounds is important for overall patient care, it is not the priority when administering magnesium sulfate. Magnesium sulfate is primarily used to prevent seizures in preeclampsia and to manage preterm labor. Its side effects can include respiratory depression, making respiratory rate the most critical assessment.

Choice B Reason:

Respiratory rate is the priority assessment when administering magnesium sulfate. Magnesium sulfate can cause respiratory depression, which can be life-threatening. Monitoring the respiratory rate helps ensure that the client is not experiencing adverse effects from the medication. The normal respiratory rate for adults is 12-20 breaths per minute.

Choice C Reason:

Temperature monitoring is important for detecting infections and other conditions, but it is not the priority in this context. Magnesium sulfate does not typically affect body temperature, so this assessment is less critical compared to respiratory rate.

Choice D Reason:

Fetal heart rate (FHR) monitoring is crucial for assessing fetal well-being, especially in clients with preeclampsia or preterm labor. However, the immediate priority when administering magnesium sulfate is to monitor the mother’s respiratory rate to prevent respiratory depression.

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Correct Answer is D

Explanation

Choice A Reason:

Covering the cord with a sterile, moist saline dressing is important to prevent the cord from drying out and to reduce the risk of infection. However, this is not the immediate priority. The primary concern is to relieve pressure on the cord to ensure adequate blood flow and oxygen to the fetus.

Choice B Reason:

Placing the client in the knee-chest position helps to relieve pressure on the umbilical cord by using gravity to shift the fetus away from the pelvis. This is a crucial step, but it should be done after manually relieving the pressure on the cord with a gloved hand.

Choice C Reason:

Preparing the client for an immediate birth is necessary if the cord prolapse cannot be resolved quickly. However, the first action should be to manually relieve the pressure on the cord to prevent fetal hypoxia while preparations for delivery are made

Choice D Reason:

Inserting a gloved hand into the vagina to relieve pressure on the cord is the immediate priority. This action directly addresses the risk of compromised blood flow and oxygen supply to the fetus, which is the most urgent concern in the case of a cord prolapse.

A. Reddened with a small amount of bloody drainage. B. Pink without drainage. C. Reddened with a scant amount of yellow exudate. D. Reddened, with copious blood.

Correct Answer is C

Explanation

Choice A Reason:

Reddened with a small amount of bloody drainage is a common finding immediately after circumcision. However, this is not the expected appearance after the initial healing phase. The presence of bloody drainage should decrease over time, and the site should begin to show signs of healing.

Choice B Reason:

Pink without drainage is not typical immediately after circumcision. The surgical site will usually be red and may have some drainage as part of the normal healing process. A completely pink and dry site would be expected only after full healing has occurred.

Choice C Reason:

Reddened with a scant amount of yellow exudate is the expected appearance during the healing process. The yellow exudate is part of the normal healing response and should not be mistaken for infection. This exudate typically appears within the first few days after circumcision and indicates that the healing process is progressing normally.

Choice D Reason:

Reddened, with copious blood is not normal and indicates a potential complication. Copious bleeding from the circumcision site requires immediate medical attention as it may suggest an issue with clotting or a problem with the surgical site.

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A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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