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The nurse reviews the assessment findings along with the healthcare provider's prescriptions.
Which immediate intervention(s) would the nurse initiate? Select all that apply.

Increase IV fluids.

Obtain blood pressure.

Stop infusion of magnesium.

Administer oxygen.

Obtain serum magnesium level.

Prepare for a cesarean delivery.

Administer calcium gluconate.

Prepare to prevent respiratory or cardiac arrest.

Answer and Explanation

Correct Answer : A,C,D,E,G

Choice A rationale

Increasing IV fluids is a critical intervention to maintain maternal hemodynamic stability and prevent complications related to fluid imbalance. It helps support blood pressure and overall fluid status during labor and delivery.

Choice B rationale

While obtaining blood pressure is important for monitoring maternal status, it is not an immediate intervention compared to others listed. Blood pressure monitoring is part of routine assessment but not an emergency action.

Choice C rationale

Stopping the infusion of magnesium is essential if there are signs of magnesium toxicity or adverse effects. Magnesium can impact respiratory and cardiac function, so stopping the infusion is a priority.

Choice D rationale

Administering oxygen is an immediate intervention to ensure adequate oxygenation for both the mother and the fetus. It is crucial during labor and delivery to prevent hypoxia and related complications.

Choice E rationale

Obtaining serum magnesium level is necessary to assess for magnesium toxicity and guide further interventions. It provides important information on the mother's magnesium status and helps in making clinical decisions.

Choice F rationale

Preparing for a cesarean delivery is not an immediate intervention unless there are specific indications for surgical delivery. It should be based on clinical findings and maternal-fetal status.

Choice G rationale

Administering calcium gluconate is the antidote for magnesium toxicity and is an immediate intervention if signs of toxicity are present. It helps counteract the effects of excessive magnesium.

Choice H rationale

Preparing to prevent respiratory or cardiac arrest is a critical intervention in severe cases of magnesium toxicity, but it should be part of a broader emergency management plan rather than an immediate action. .

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Correct Answer is D

Explanation

Stopping oxygen per cannula after uterine hyperstimulation and subsequent contraction reduction is not appropriate. Oxygen should be continued to ensure fetal oxygenation, particularly after a period of stress caused by frequent contractions. Discontinuing oxygen too soon may compromise fetal well-being.

Choice B rationale

Checking for clonus in both feet is unrelated to the management of uterine contractions post-oxytocin administration. Clonus assessment is used in evaluating neuromuscular function, often in conditions such as preeclampsia, but not for monitoring uterine activity or response to oxytocin.

Choice C rationale

Notifying the nursery about the client's response is important for continuity of care but does not address the immediate need to manage the uterine contractions. The primary focus should be on stabilizing uterine activity before updating other departments.

Choice D rationale

Restarting the oxytocin infusion rate per protocol is the correct intervention after ensuring that the contractions have reduced to a safe frequency and duration. This approach helps to maintain labor progress while minimizing the risk of hyperstimulation and fetal distress. The nurse should follow the hospital's guidelines for oxytocin titration.

A. A. Hypoglycemia. B. Polycythemia. C. Hyperthermia. D. Hyperbilirubinemia. E. None F. None

Correct Answer is A

Explanation

Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.

Choice B rationale

Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.

Choice C rationale

Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.

Choice D rationale

Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.

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The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

Correct Answer is A

Explanation

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The nurse reviews the assessment findings along with the healthcare provider's prescriptions.
Which immediate intervention(s) would the nurse initiate? Select all that apply.