The nurse is caring for a patient who is receiving magnesium sulfate for pre-eclampsia. Which assessments will be of the highest priority?

Correct Answer: A

Rationale: The correct answer is A because magnesium sulfate can cause respiratory depression, necessitating close monitoring of lung sounds to detect any signs of respiratory distress. Assessing lung sounds is crucial for early detection and intervention. Blood sugar level (B) monitoring is not directly related to magnesium sulfate therapy. Encouraging fluid intake (C) may be important, but not as critical as assessing lung sounds. Assessing for pitting edema (D) is important for overall assessment but not the highest priority in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Abdominal cramping and lower back pain. This symptom is consistent with preterm labor as it indicates contractions and possible cervical changes. Severe pain in the lower quadrant (A) is more likely related to other conditions like ectopic pregnancy. Severe pain and hard abdomen to palpation (B) may suggest a more acute issue like placental abruption. Painless vaginal bleeding (C) is typically seen in conditions like placenta previa. Therefore, choice D is the most indicative of preterm labor based on the symptoms presented.

Correct Answer: C

Rationale: The correct answer is C: Being an adolescent. Adolescents are more prone to hyperemesis gravidarum due to several factors such as hormonal changes, increased stress, poor diet, and lack of prenatal care awareness. Being an adolescent increases the risk of complications during pregnancy leading to hyperemesis gravidarum. High levels of hCG (choice A) are a symptom rather than a cause of hyperemesis gravidarum. High blood pressure (choice B) and being underweight (choice D) are not directly linked to the development of hyperemesis gravidarum in adolescents.

Correct Answer: B

Rationale: The correct answer is B: Fluid volume deficit. When a pregnant client at 30 weeks experiences a gush of fluid from the vagina, it may indicate ruptured membranes leading to amniotic fluid leakage. This can lead to a decrease in amniotic fluid volume, potentially causing fluid volume deficit for both the mother and the fetus. This can result in complications such as preterm labor, infection, and fetal distress. The other choices are incorrect because: A: Infection is a potential risk due to the ruptured membranes, but the immediate concern is fluid volume deficit. C: Hypotension is not directly related to the scenario described. D: Decreased urinary output is not a typical immediate concern with ruptured membranes; rather, the focus should be on assessing for signs of fluid loss and ensuring hydration.

Correct Answer: B

Rationale: The correct answer is B. Getting baseline blood pressure and pulse and monitoring frequently during administration is crucial because hydralazine is a potent antihypertensive medication that can cause significant drops in blood pressure. Monitoring allows for early detection of hypotension or adverse reactions. A is incorrect because positioning the client supine with the head of the bed elevated 30 degrees is not specific to the administration of hydralazine for pre-eclampsia. C is incorrect because administering medication every 5 minutes until blood pressure is stabilized is not a standard protocol for hydralazine administration; it should be given as per physician's orders with appropriate monitoring. D is incorrect because informing the client about a positive direct Coombs test result is not relevant to the administration of hydralazine; this is more pertinent to medications that can cause hemolytic anemia.