A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)

Correct Answer: D

Rationale: The correct answer is D: All of the above. Magnesium sulfate toxicity can lead to respiratory depression (respirations less than 12/min), decreased urinary output (less than 25 mL/hr), and altered mental status (decreased level of consciousness). Respiratory depression occurs due to the impact of magnesium on the central nervous system. Decreased urinary output is a result of magnesium's effects on renal blood flow. Altered mental status is a common sign of magnesium toxicity affecting brain function. Reporting these signs promptly is crucial to prevent serious complications. The other choices (A, B, C) are incorrect because they are all potential signs of magnesium sulfate toxicity and should be reported.

Correct Answer: C

Rationale: The correct action is to assist the client to the hands and knees position. This position, also known as the all-fours position, can help alleviate back pain by encouraging the baby to rotate into a more favorable position for delivery. By being on hands and knees, gravity assists in the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially facilitate a smoother labor progress. Effleurage (choice A) may provide comfort but doesn't address the positional issue. Placing the client in lithotomy position (choice B) can worsen the occiput posterior position. Applying a scalp electrode to the fetus (choice D) is not indicated in this scenario.

Correct Answer: C

Rationale: The correct answer is C because continuing to take insulin during nausea and vomiting is crucial for maintaining blood glucose control in clients with diabetes. Nausea and vomiting can lead to decreased food intake, risking hypoglycemia if insulin is not adjusted. Choice A is incorrect because fasting blood glucose levels should ideally be maintained between 60-90 mg/dL in pregnant clients with diabetes for optimal outcomes, not 100-120 mg/dL. Choice B is incorrect because engaging in moderate exercise when blood glucose is high (250 or higher) can exacerbate hyperglycemia rather than help in lowering blood glucose levels. Choice D is incorrect because avoiding exercise when blood glucose exceeds 250 is not recommended. Exercise can help lower blood glucose levels and improve insulin sensitivity.

Correct Answer: D

Rationale: The correct answer is D because during the taking-hold phase, the client is focused on learning and mastering new skills related to caring for the newborn. Demonstrating how to perform a newborn bath aligns with this phase as it helps the client gain confidence and competence in newborn care. Discussing contraceptive options (choice A) is more appropriate during the let-go phase. Repeating information (choice B) may be necessary but is not the priority during the taking-hold phase. Listening to the client and her partner reflect on the birth experience (choice C) is important for emotional support but not specifically related to the behavioral adjustments in the taking-hold phase.

Correct Answer: D

Rationale: The correct answer is D because the acoustic vibration device is used during a nonstress test to wake up a sleeping fetus, ensuring that the baby is active and responsive during the test. This helps to assess the baby's well-being and monitor its heart rate patterns. Choice A is incorrect as the device does not stimulate uterine contractions. Choice B is incorrect as it does not decrease the incidence of contractions. Choice C is incorrect as the device does not lull the fetus to sleep, but rather ensures the fetus is awake and moving during the test.

Correct Answer: B

Rationale: The correct answer is B: Lecithin/sphingomyelin (L/S) ratio. This test is used to assess fetal lung maturity by determining the ratio of two substances present in amniotic fluid. An L/S ratio of 2:1 or higher indicates mature fetal lungs, reducing the risk of respiratory distress syndrome in preterm infants. A: Alpha-fetoprotein (AFP) is used to screen for neural tube defects, not fetal lung maturity. C: Kleihauer-Betke test is used to detect fetal-maternal hemorrhage. D: Indirect Coombs' test is used to detect antibodies in maternal blood that may attack fetal red blood cells, not assess fetal lung maturity. In summary, the L/S ratio test is the most appropriate choice to assess fetal lung maturity during preterm labor, as it directly correlates with the development of the fetal lungs.

Correct Answer: C

Rationale: The correct answer is C: You should empty your bladder before the procedure. This is important because a full bladder can obstruct the visualization of the fetus during amniocentesis. By emptying the bladder, the uterus is better positioned for the procedure, making it safer and more effective. Explanation: 1. A (You will lie on your right side during the procedure) is incorrect because the position during amniocentesis is typically on the back or slightly tilted to the left. 2. B (You should not eat anything for 24 hours before the procedure) is incorrect as fasting is not required for amniocentesis. 3. D (The test is performed to determine gestational age) is incorrect as amniocentesis is used to detect genetic abnormalities, not gestational age.

Correct Answer: D

Rationale: The correct answer is D because it demonstrates an understanding of the importance of calcium intake for breastfeeding mothers. Calcium is essential for both the mother's health and the baby's bone development. Continuing calcium supplements shows a commitment to meeting nutritional needs. Incorrect choices: A: Having coffee is fine, but it's not directly related to postpartum nutrition needs. B: Folic acid is important for pregnancy but not specifically for increasing milk supply. C: While additional calories are needed during breastfeeding, the specific amount varies and is not always 330 calories per day.

Correct Answer: D

Rationale: The correct answer is D: Decreased urine output. At 26 weeks of gestation, decreased urine output can be a sign of potential complications like preeclampsia or dehydration, which require immediate medical attention to prevent harm to the mother and baby. Leukorrhea (choice A) is a common pregnancy symptom and not typically concerning. Supine hypotension (choice B) is a known issue in pregnancy but usually occurs later in the third trimester due to pressure on the vena cava when lying on the back. Periodic numbness of the fingers (choice C) can be related to carpal tunnel syndrome, which is common in pregnancy but not typically urgent at 26 weeks unless severe and persistent.