A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?

Correct Answer: D

Rationale: The correct answer is D) Urine output 90 ml/4 hours, indicating magnesium sulfate toxicity in a client with severe preeclampsia. Magnesium sulfate toxicity can lead to decreased urine output due to renal failure, a serious complication. This is a critical sign for the nurse to recognize and intervene promptly to prevent further harm to the client. Option A) Deep tendon reflexes 2+ is a normal finding and not indicative of magnesium sulfate toxicity. Option B) Blood pressure 140/90 is within normal range for a pregnant client with preeclampsia and does not specifically indicate magnesium sulfate toxicity. Option C) Respiratory rate 18/minute is also a normal finding and not a specific indicator of magnesium sulfate toxicity. In an educational context, understanding the signs and symptoms of magnesium sulfate toxicity is crucial for nurses caring for maternal and reproductive health clients. Recognizing these signs promptly can help prevent serious complications and ensure the best outcomes for both the mother and the baby. Regular assessments and knowledge of potential complications are essential in providing safe and effective care to these clients.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is option A, which is to measure bilirubin levels using a transcutaneous bilirubinometer. This is the most appropriate initial step when observing a yellow tint to the skin in a newborn, as it helps in assessing for jaundice, a common condition in newborns due to the breakdown of red blood cells. Option B, reviewing maternal medical records for blood type and Rh factor, is not the immediate action required when assessing jaundice in a newborn. While maternal factors can contribute to neonatal jaundice, assessing bilirubin levels in the newborn is more crucial at this point. Option C, preparing the newborn for phototherapy, is premature without knowing the actual bilirubin levels. Phototherapy is a treatment for severe jaundice, but it should be based on bilirubin level results. Option D, evaluating cord results, is not the priority in this situation. While cord blood can provide some information, direct assessment of the newborn's bilirubin levels through a transcutaneous bilirubinometer is more immediate and accurate. Educationally, this question highlights the importance of prompt assessment and intervention in newborn care. Understanding the significance of jaundice in newborns and the appropriate steps to take is crucial for nurses working in maternal and newborn health settings. Early detection and management of jaundice can prevent complications and ensure optimal outcomes for the newborn.

Correct Answer: D

Rationale: The correct action for the nurse to implement in this scenario is to instruct the client to use deep breathing during contractions (Option D). Deep breathing techniques can help the client manage labor pain effectively by promoting relaxation, reducing stress, and increasing oxygen flow to the body and baby. It is a non-pharmacological method that can be safely used in conjunction with other pain relief interventions. Option A, discontinuing the Pitocin infusion, is incorrect because the client is only at 3 cm dilation and stopping the oxytocin could potentially slow down labor progress. Option B, medicating the client with an additional 1 mg of Stadol IV push, is inappropriate as the client was already medicated 30 minutes ago, and overmedication can lead to respiratory depression in the mother and newborn. Option C, notifying the healthcare provider, is not immediately necessary as the situation does not require urgent provider intervention. Educationally, it is crucial for nurses to be knowledgeable about non-pharmacological pain management strategies during labor and understand the appropriate timing and dosages of pain medications to ensure safe and effective care for maternal and reproductive health clients. Teaching clients coping techniques like deep breathing empowers them to participate actively in their care and enhances their birthing experience.

Correct Answer: A

Rationale: The correct answer is A) Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. This response is the best because it directly addresses the physiological rationale behind the prescription of bedrest for a pregnant client with mitral stenosis Class III. Mitral stenosis is a condition where the mitral valve in the heart is narrowed, leading to decreased blood flow from the left atrium to the left ventricle. By staying in bed, the client reduces physical exertion, which in turn reduces the oxygen demand on the heart muscle. This helps to prevent further strain on the heart and minimizes the risk of complications such as heart failure or arrhythmias during pregnancy. Option B) You have a small opening in your heart and complete bedrest will help it get bigger is incorrect as it provides inaccurate information about the condition of mitral stenosis and the purpose of bedrest. Bedrest does not make the opening in the heart larger. Option C) We want your baby to be healthy, and this is the only way we can make sure that will happen is incorrect as it focuses solely on the well-being of the baby without addressing the specific medical needs of the mother with mitral stenosis. Option D) Labor is difficult, and you need to save your energy so you will be strong enough then is incorrect as it does not address the immediate concern of reducing the strain on the heart due to mitral stenosis during pregnancy. In an educational context, it is important for nurses to understand the rationale behind medical interventions prescribed for clients with specific health conditions. Providing accurate and clear explanations to clients helps them understand the importance of following medical recommendations and promotes better adherence to treatment plans.

Correct Answer: A

Rationale: In this scenario, option A is the correct answer because edema, basilar rales, and an irregular pulse are indicative of worsening heart failure in a pregnant woman with pre-existing heart disease during the second stage of labor. Option B, increased urinary output, and tachycardia could be normal physiological responses during labor and may not necessarily indicate a complication related to the woman's heart disease. Option C, dyspnea, bradycardia, and hypertension are also concerning symptoms, but in the context of a woman with pre-existing heart disease, these findings might suggest other issues rather than worsening heart failure. Option D, a regular heart rate, and hypertension is not as concerning as the symptoms listed in option A, as hypertension alone may be managed in a woman with pre-existing heart disease. Educationally, this question highlights the importance of recognizing the unique needs and risks associated with maternal and reproductive health clients, especially those with pre-existing conditions. It emphasizes the necessity of thorough assessment and critical thinking in identifying potential complications during labor and delivery to provide safe and effective care for both the mother and the baby.