Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?

Correct Answer: C

Rationale: The correct answer is C: Normal deep tendon reflexes. This assessment indicates a therapeutic level of magnesium sulfate as it suggests that the medication is effectively preventing magnesium toxicity which would typically present as hyperreflexia or absent reflexes. Drowsiness (A) may indicate magnesium toxicity, urinary output of 20 mL/hour (B) may indicate renal impairment, and a respiratory rate of 10 to 12 breaths per minute (D) may indicate respiratory depression, all of which are signs of magnesium sulfate toxicity rather than therapeutic levels.

Correct Answer: C

Rationale: The priority nursing intervention for a patient with incomplete abortion is to ensure fluid replacement by inserting an IV line (Choice C). This is crucial to address potential hypovolemia and prevent further complications. Providing medication (Choice A) or positioning the patient (Choice D) is important but not as immediate as ensuring fluid replacement. Preoperative teaching (Choice B) is not necessary until the patient is stable.

Correct Answer: B

Rationale: The correct answer is B: Administration of methotrexate. This is the priority intervention for a patient with an intact tubal pregnancy as it helps to stop the growth of the pregnancy tissue in the fallopian tube, reducing the risk of rupture and potentially saving the patient's life. Administering methotrexate promptly is crucial in managing tubal pregnancies. Assessing pain level (choice A) is important but not the priority in this case. Administration of Rh immune globulin (choice C) is not necessary for an intact tubal pregnancy. Explanation of common side effects (choice D) can be done after the priority intervention.

Correct Answer: A

Rationale: The correct answer is A: 6:30 AM on January 13. RhoGAM should be administered within 72 hours after delivery to prevent Rh isoimmunization. Since the patient delivered at 6:30 AM on January 10, the administration should be done before 6:30 AM on January 13 to ensure it falls within the 72-hour window. Choices B, C, and D fall outside this critical timeframe and would not be appropriate for administering RhoGAM.

Correct Answer: A

Rationale: The correct answer is A: Hypoglycemia. Infants of diabetic mothers are at risk for hypoglycemia due to excessive insulin production in response to high maternal blood glucose levels. Monitoring blood glucose levels is crucial to prevent complications. Hypercalcemia (B) is not typically associated with infants of diabetic mothers. Hypoinsulinemia (C) refers to low insulin levels, which is not a major concern in this context. Hypobilirubinemia (D) is low levels of bilirubin and is not a common complication in infants of diabetic mothers.