A patient taking magnesium sulfate has a respiratory rate of 10 breaths per minute. In addition to discontinuing the medication, which action should the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Administer calcium gluconate. Magnesium sulfate can cause respiratory depression, leading to a low respiratory rate. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on the neuromuscular junction. Administering calcium gluconate helps reverse the respiratory depression caused by magnesium sulfate. Increasing IV fluids (Choice A) is not directly related to treating respiratory depression. Vigorously stimulating the patient (Choice C) can exacerbate respiratory depression. Instructing the patient to take deep breaths (Choice D) may not be effective in addressing the underlying cause of respiratory depression due to magnesium sulfate toxicity.

Correct Answer: C

Rationale: The correct answer is C: Clear fluid from vagina. In threatened abortion, there is vaginal bleeding but the cervix is closed, indicating the possibility of the pregnancy continuing. If clear fluid is present, it suggests rupture of the amniotic sac, leading to inevitable abortion. Backache (A) and pelvic pressure (D) can be common symptoms in both threatened and inevitable abortion. A rise in hCG level (B) alone does not indicate a change from threatened to inevitable abortion.

Correct Answer: C

Rationale: The correct answer is C: Degree of glycemic control before and during the pregnancy. Proper glycemic control is crucial in managing complications in a pregnant patient with diabetes. Uncontrolled blood sugar levels can lead to maternal, fetal, and neonatal complications. Monitoring and maintaining stable blood glucose levels before and during pregnancy help reduce the risk of adverse outcomes. A: Evaluation of retinopathy by an ophthalmologist - Although important for overall health, retinopathy does not directly impact maternal, fetal, and neonatal complications in diabetes during pregnancy. B: The patient’s stable emotional and psychological status - While emotional and psychological well-being are important, they do not directly affect complications related to diabetes in pregnancy. D: Total protein excretion and creatinine clearance within normal limits - While these are indicators of kidney function, they are not the most crucial factors in managing complications in a pregnant patient with diabetes.

Correct Answer: B

Rationale: The correct answer is B because pregnant patients with Class II heart disease should avoid strenuous activity to prevent further strain on the heart. Strenuous activity can increase the risk of complications in these patients. Option A is incorrect as excessive weight gain can exacerbate heart disease. Option C is incorrect because limiting fluid intake can lead to dehydration, which is harmful during pregnancy. Option D is incorrect as a diet high in calcium is not specifically indicated for pregnant patients with Class II heart disease.

Correct Answer: A

Rationale: The correct answer is A because the postpartum patient who has had four saturated pads during the last 12 hours should receive further assessment. This indicates excessive postpartum bleeding (postpartum hemorrhage), which is a critical complication that requires immediate intervention to prevent complications like hypovolemic shock. Monitoring vital signs, assessing for signs of shock, evaluating uterine tone, and determining the cause of bleeding are crucial steps in managing postpartum hemorrhage. Choices B, C, and D are not the correct answers because: B: A patient with Class II heart disease complaining of frequent coughing is more likely experiencing cardiac-related issues and requires evaluation and management by a cardiologist. C: A patient with gestational diabetes and a fasting blood sugar level of 100 mg/dL is within the normal range and does not require immediate further assessment. D: A postcesarean patient with active herpes lesions on the labia requires appropriate management of the herpes infection but does not necess