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: Assessing lung sounds. This is of highest priority because magnesium sulfate can lead to respiratory depression. Assessing lung sounds helps monitor for signs of respiratory distress, such as decreased breath sounds or crackles. Assessing blood sugar level (B) is important but not as urgent as respiratory status. Encouraging fluid intake (C) is important for hydration but not as critical as respiratory assessment. Assessing for pitting edema (D) is relevant for monitoring fluid retention but not as immediate as assessing lung sounds for respiratory compromise.

Correct Answer: D

Rationale: The correct answer is D: Abdominal cramping and lower back pain. These symptoms are typical of preterm labor due to the contractions of the uterus. Lower back pain is a common sign of labor, and abdominal cramping is indicative of uterine contractions. Severe pain in the lower quadrant (A) is more consistent with issues like appendicitis. Severe pain and hard abdomen (B) may indicate a more serious condition like placental abruption. Painless vaginal bleeding (C) is more characteristic of conditions like placenta previa. Therefore, choice D is the most appropriate in the context of suspected preterm labor.

Correct Answer: C

Rationale: The correct answer is C: Being an adolescent. Adolescents are at higher risk for hyperemesis gravidarum due to hormonal changes and inadequate nutritional intake. Adolescents often experience rapid growth and increased nutritional demands, leading to a higher susceptibility to conditions like hyperemesis gravidarum. High levels of hCG (A) are common in pregnancy and can contribute to nausea and vomiting but are not the primary cause of hyperemesis gravidarum. High blood pressure (B) is not directly related to hyperemesis gravidarum. Being underweight (D) may exacerbate the condition but is not the primary factor causing hyperemesis gravidarum in this case.

Correct Answer: B

Rationale: The correct answer is B: Fluid volume deficit. When a pregnant client experiences a gush of fluid from the vagina at 30 weeks, it could indicate premature rupture of membranes (PROM) or preterm premature rupture of membranes (PPROM). This increases the risk of amniotic fluid leakage, leading to a decrease in the fluid surrounding the fetus. This can result in a fluid volume deficit for the fetus, potentially leading to complications such as fetal distress or preterm labor. In contrast, choices A, C, and D are less likely in this scenario. Infection (choice A) could be a risk later if the membranes are ruptured for an extended period. Hypotension (choice C) and decreased urinary output (choice D) are not directly related to the gush of fluid and are less likely in this immediate situation.

Correct Answer: B

Rationale: The correct answer is B. The nurse should get baseline blood pressure and pulse and monitor frequently during administration to assess the effectiveness and safety of the medication. This is crucial in managing severe pre-eclampsia. Choice A is incorrect because the client should be positioned on her left side to prevent vena cava compression, not supine with the head of the bed elevated. Choice C is incorrect because administering medication every 5 minutes without proper monitoring can lead to adverse effects like hypotension. Choice D is incorrect because hydralazine does not cause a positive direct Coombs test result. It is important for the nurse to provide accurate information to the client.