A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity?

Correct Answer: A

Rationale: Rationale: The correct answer is A) Serial grip strengths. When a client is on magnesium sulfate therapy for severe preeclampsia, monitoring for signs of magnesium toxicity is crucial. Serial grip strength assessments are important because magnesium toxicity can lead to neuromuscular complications such as muscle weakness or loss of deep tendon reflexes. By assessing grip strength regularly, the nurse can detect these early signs of toxicity and intervene promptly to prevent further complications. Option B) Kernig assessments are used to assess for meningitis, not magnesium sulfate toxicity. Option C) Pupillary responses are important for assessing neurological status but are not specific to monitoring magnesium toxicity. Option D) Apical heart rate checks are important for monitoring cardiac function but do not specifically indicate magnesium toxicity. Educational context: Understanding the signs and symptoms of magnesium sulfate toxicity is essential for nurses caring for clients with severe preeclampsia. By regularly assessing grip strength, nurses can identify early signs of magnesium toxicity and prevent serious complications. This knowledge and skill are critical for providing safe and effective care to perinatal clients at risk for complications related to hypertension in pregnancy.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Fundus firm at umbilicus. Methergine is a medication commonly used to prevent or control postpartum hemorrhage by promoting uterine contractions. The firmness of the fundus at the level of the umbilicus indicates effective contraction of the uterus, which helps prevent excessive bleeding after childbirth. Option A: Blood pressure 120/80 is not a direct indicator of the effectiveness of Methergine in preventing postpartum hemorrhage. While stable blood pressure is important, it is not a specific indicator of the medication's effectiveness in this context. Option B: Pulse rate 80 bpm and regular is also not a direct indicator of the medication's effectiveness in preventing postpartum hemorrhage. A normal pulse rate is important but does not directly reflect uterine contraction and prevention of hemorrhage. Option D: Increase in prothrombin time is incorrect because an increase in prothrombin time would actually suggest a disturbance in the blood's ability to clot, which is not the desired effect of Methergine in this situation. Educationally, understanding the rationale behind the correct answer helps nurses recognize the appropriate assessment findings to monitor after administering Methergine in postpartum care. This knowledge is crucial for providing safe and effective care to postpartum patients and preventing complications such as postpartum hemorrhage.

Correct Answer: A

Rationale: The correct answer is A) The mother's nipples are soft to the touch. This indicates successful manual expression of breast milk. When the mother is able to express milk manually, it helps in relieving the engorgement, allowing for easier feeding for the baby. Soft nipples suggest effective milk removal from the breasts, improving milk flow and facilitating feeding. Option B) The baby swallows after every 5th suck is incorrect as it does not directly indicate successful manual expression by the mother. It focuses more on the baby's feeding pattern. Option C) The baby's pre- and postfeed weight change is 20 milliliters is incorrect as it pertains to the baby's weight change, not the mother's ability to express milk. Option D) The mother squeezes her nipples during manual expression is incorrect as it describes the action taken by the mother, not the outcome or success of the intervention. In an educational context, this question highlights the importance of recognizing and managing engorgement in breastfeeding mothers to ensure successful breastfeeding. Teaching mothers how to manually express milk can be a crucial skill to alleviate engorgement and improve breastfeeding outcomes for both mother and baby.

Correct Answer: A

Rationale: Placenta accreta is a serious obstetric complication where the placenta attaches too deeply into the uterine wall. In this scenario, the correct answer is A) Blood loss of 2000 mL. Placenta accreta can lead to significant blood loss during delivery due to the abnormal attachment of the placenta, which can cause difficulty in separating it from the uterine wall without excessive bleeding. Option B) Blood pressure of 160/110 is incorrect because while hypertension can be a complication of placenta accreta due to blood loss, it is not a direct result of the condition itself. Option C) Jaundice skin color is incorrect as it is not a typical symptom of placenta accreta. Jaundice is usually associated with liver or hemolytic disorders. Option D) Shortened prothrombin time is incorrect because placenta accreta is more likely to cause coagulation abnormalities resulting in prolonged, not shortened, prothrombin time. In an educational context, understanding the complications associated with placenta accreta is crucial for nurses caring for women during childbirth. Recognizing the signs and symptoms of this condition is essential for timely intervention and preventing severe maternal outcomes. By knowing the correct maternal complications, nurses can provide appropriate care and support to ensure the best possible outcomes for both the mother and the baby.