The nurse caring for a client receiving magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
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Solution
Answer B is correct. The client is expected to become sleepy, have hot flashes, and experience lethargy. A decreasing urinary output, absence of the knee jerk reflex, and decreased respirations are signs of toxicity and are not expected side effects of magnesium sulfate. Therefore, answers A, C, and D are incorrect.
Which observation in the newborn of a mother who is alcohol dependent would require immediate nursing intervention?
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Solution
Answer C is correct. Jitteriness is a sign of seizure in the neonate. Answers A, B, and D are incorrect because crying, wakefulness, and yawning are expected in the newborn.
A multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1. The nurse’s assessment of this data is:
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Solution
Answer C is correct. When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer B is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, as stated in answer D.
Which medication should be used with caution in the obstetric client with diabetes?
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Solution
Answer B is correct. Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so there is no need to question the order for these medications.
The nurse is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex?
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Solution
Answer A is correct. The answer can only be A because the other methods elicit different reflexes. Answer B elicits the triceps reflex, answer C elicits the patella reflex, and answer D elicits the radial nerve.
Which laboratory finding is associated with HELLP syndrome in the obstetric client?
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Solution
Answer D is correct. The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased in HELLP syndrome, not elevated, as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome, as stated in answer C.
A client visiting a family planning clinic is suspected of having an STI. The most diagnostic test for treponema pallidum is:
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Solution
Answer C is correct. FTA is the only answer choice for treponema pallidum. Answers A and B are incorrect because VDRL and RPR are screening tests for syphilis but are not conclusive of the disease; they only indicate exposure to the disease. The ThayerMartin culture is a test for gonorrhea, so answer D is incorrect.
The client seen in the family planning clinic tells the nurse that she has a painful lesion on the perineum. The nurse is aware that the most likely source of the lesion is:
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Solution
Answer B is correct. A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. In answer C, candidiasis is a yeast infection and does not present with a lesion, but it is exhibited by a white, cheesy discharge. Condylomata lesions are painless warts, so answer D is incorrect.
A client with a diagnosis of human papillomavirus (HPV) is at risk for which of the following?
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Solution
Answer B is correct. The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.
A papular lesion is noted on the perineum of the laboring client. Which initial action is most appropriate?
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Solution
Answer B is correct. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect