A nurse is speaking on the phone to a client who is pregnant and taking iron supplements for iron-deficiency anaemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?
"Go to the emergency room and your provider will meet you there.".
"What else have you been eating?.".
"This is expected because of the way iron is broken down during digestion.".
"Come to the office, and we will check things out.".
The Correct Answer is C
Choice C rationale:
This response is correct because black stools are a common side effect of taking iron supplements. Iron can cause the stool to appear black or
tarry due to the way it is broken down during digestion. It does not necessarily indicate a serious issue, especially if the client is not experiencing any abdominal pain or cramping. Educating the client about this expected side effect helps alleviate any concerns they might have about the change in stool colour.
Choice A rationale:
"Go to the emergency room and your provider will meet you there.”. This response is not appropriate in this situation. The client's report of black stools without abdominal pain or cramping is likely due to the iron supplements and does not warrant a visit to the emergency room. This response may cause unnecessary panic and anxiety for the client.
Choice B rationale:
"What else have you been eating?.”. This response is also not the best choice. While it's essential for healthcare providers to gather comprehensive information about a client's diet and lifestyle, in this case, the client's black stools can be directly attributed to the iron supplements. Focusing on other dietary factors might distract from addressing the client's concern about the side effect of iron supplementation.
Choice D rationale:
"Come to the office, and we will check things out.”. This response is not the most appropriate one either. A visit to the office might not be necessary solely based on the client's report of black stools without accompanying pain or cramping. This situation can be managed through education, and the client can be reassured that it is a typical side effect of iron supplements. An unnecessary visit to the office could inconvenience the client and waste both their time and the healthcare provider's time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: Respiratory rate of 16/min.
Choice A rationale:
A respiratory rate of 16/min is within the normal range for adults, which is typically between 12 to 20 breaths per minute. In the context of severe preeclampsia, maintaining a normal respiratory rate is crucial when administering magnesium sulfate IV, as one of the signs of magnesium toxicity is respiratory depression. Therefore, a respiratory rate of 16/min indicates that the client is not experiencing respiratory depression and it is safe to continue the magnesium sulfate infusion.
Choice B rationale:
A heart rate of 60/min is at the lower end of the normal range, which is 60 to 100 beats per minute for adults. However, bradycardia or a low heart rate can be a sign of magnesium sulfate toxicity, especially if accompanied by other symptoms such as hypotension or altered mental status. Without additional context, a heart rate of 60/min alone does not necessarily indicate it is unsafe to continue the infusion, but it would require further assessment.
Choice C rationale:
A urine output of 50 mL in 4 hours is significantly below the expected minimum of 30 mL/hour for adults. Adequate urine output is an important indicator of kidney function and is essential for the excretion of magnesium. In the case of magnesium sulfate infusion for severe preeclampsia, a low urine output could indicate renal insufficiency and an increased risk of magnesium toxicity. Therefore, a urine output of 50 mL in 4 hours is a contraindication for continuing the infusion without further evaluation.
Choice D rationale:
Diminished deep-tendon reflexes can be a sign of magnesium toxicity. Deep-tendon reflexes are assessed to monitor for signs of magnesium overdose during infusion, as magnesium acts as a central nervous system depressant at high levels. If deep-tendon reflexes are diminished, it may suggest that the serum magnesium levels are too high, and the infusion should be paused or discontinued to prevent further toxicity.
In summary, the only finding that clearly indicates it is safe to continue the magnesium sulfate infusion is a normal respiratory rate, as provided in choice A. The other options either require further assessment or are indicators of potential magnesium toxicity.
Correct Answer is A
Explanation
Choice A rationale:
Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.
Choice B rationale
Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.
Choice C rationale
Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.
Choice D rationale
Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.
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