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1. A pregnant client is receiving magnesium sulfate therapy for the control of preeclampsia. A nurse discover that the client is encountering toxicity from the medication in which of the following assessment?
- Urine output of 25 ml/hr.
- The presence of deep tendon reflex.
- Respirations of 10 breaths per minute.
- Serum magnesium level of 7 mEq/L.
2. A student nurse was asked by the nurse instructor to explain the procedure for the administration of erythromycin ointment to the eyes of the newborn. Which of the following statements made by the student indicates a need for further research?
- “I will instill the eye ointment into each of the newborn‘s conjunctival sacs.”
- “I will flush the newborn‘s eyes after instilling the ointment.”
- “I will clean the newborn‘s eyes before instilling the ointment.”
- “I need to administer the eye ointment within an hour after maternal delivery.”
3. Rho(D) immune globulin (RhoGAM) is given to a pregnant woman after delivery and the nurse is giving information to the patient about the indication of the medication. The nurse determines that the patient understands the purpose of the medication if the patient tells that it will protect her baby from which of the following?
- Developing German Measles.
- Developing Pernicious anemia.
- Developing Rh incompatibility.
- Having an RH+ blood.
4. A pregnant woman who is having labor pains is receiving an opioid analgesic. Which of the following medications should be ready in case a respiratory depression occurs?
- Naloxone (Narcan).
- Oxycodone (Oxycontin).
- Meperidine hydrochloride (Demerol).
- Morphine sulfate.
5. Methylergonovine (Methergine) is prescribed to a patient who is having a postpartum bleeding. Prior giving the medication, the nurse contacts the physician who prescribed the medication if which of the following condition is documented in the patient’s chart?
- Ischemic heart disease.
- Diabetes Mellitus.
- Acute Gastroenteritis.
6. A nurse instructor is about to administer a vitamin K injection to a newborn. The student nurse asks the instructor regarding the purpose of the injection. The appropriate response would be:
- “The vitamin K provides active immunity.”
- “The vitamin K will prevent the occurrence of hyperbilirubinemia.”
- “The vitamin K will protect the newborn from bleeding.”
- “The vitamin K will serve as protection against jaundice and anemia.”
7. A nurse is assigned to a patient who is receiving Oxytocin (Pitocin) to induce labor. The nurse terminates the oxycontin infusion if which of the following is noted on the assessment of the client?
- Early decelerations of the fetal heart rate.
- Uterine hyperstimulation.
8. A client in preterm labor (32 weeks) who is dilated to 5cm has been given magnesium sulfate and the contractions have stopped. If the labor can be delayed for the next 2 days, which of the following medication does the nurse expect that will be prescribed?
- Fentanyl (Sublimaze).
- Sufentanil (Sufenta).
- Betamethasone (Celestone).
- Butorphanol tartrate (Stadol).
9. Which of the following laboratory test must be monitored for pregnant patients receiving dexamethasone?
- Red blood cell count.
- Serum Calcium.
- Random blood sugar.
- Uric acid.
10. Patellar reflex is being monitored for patients receiving magnesium sulfate therapy. When assessing the deep tendon reflex, which of the following grade pertains to diminished response?
- Grade 0
- Grade 1
- Grade 2
- Grade 4
11. Prior giving of Methylergonovine, what is the priority assessment for the nurse to check which of the following?
- Deep tendon reflexes.
- Urine output.
- Blood pressure.
- Vaginal bleeding.
12. A nurse is preparing to give a lung surfactant to a 36 weeks old baby with a respiratory distress syndrome. Which of the following is the correct route of administration?
13. A nurse is preparing to administer a Rubella vaccine to a client prior discharge home. Which of the following is not true regarding this vaccine?
- Pain, redness, swelling, or a lump is some of the adverse reaction.
- Given intramuscularly in the lateral aspect of the middle third of the vastus lateralis muscle.
- The need to use of contraception after immunization.
- Contraindicated in a client with an allergy to duck eggs.
14. A nurse is preparing Dinoprostone to a client to induce labor. Which of the following nursing intervention must be questioned?
- Have the client hold void before administration.
- Place the client on a side lying position for 30 to 60 minutes after the administration.
- Monitor maternal vital signs.
- Have the client void before administration.
15. A nurse is caring for a patient receiving oxytocin therapy suddenly is experiencing hypertonic contractions. Which of the following priority nursing actions should the nurse do? Select all that apply.
- The nurse leaves the client to ask for help.
- Stop the oxytocin infusion.
- Increase the flow rate of the intravenous additive solution.
- Place the client in the supine position.
- Administer oxygen at 8 to 10 liters per minute.
Answers and Rationale
1. Answer: C. Respirations of 10 breaths per minute. Magnesium sulfate is a central nervous system depressant and anticonvulsant. It can cause smooth muscle relaxation. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, decreased urine output, loss of deep tendon reflexes, hypotension and a decrease maternal and fetal heart rate.
- Option A: Urine output should be maintained at 25-30ml/hr.
- Option B: Deep tendon reflexes must be present.
- Option D: Normal range for magnesium is between 4-7 mEq/L
2. Answer: B. “I will flush the newborn‘s eyes after instilling the ointment.” Newborn eye prophylaxis is used for the protection against Gonorrhea or Chlamydia infection. The eyes are not flushed following the instillation of the medication because it will wash away the administered ointment.
- Option A: The correct administration of the ointment.
- Option C: Cleaning the newborn‘s eye before instilling the ointment is a standard procedure.
- Option D: Instillation of eye ointment can be delayed for 1 hour to facilitate eye contact and parent-newborn bonding.
3. Answer: C. Developing Rh incompatibility. Rh incompatibility can develop when a Rh-negative mother becomes sensitized to the RH antigen. Sensitization may occur when a Rh-negative woman becomes pregnant with a fetus who is Rh positive. Blood cells from the baby may cross the maternal bloodstream, which can happen during pregnancy, labor, and delivery, causing the mother’s immune system to form antibodies, against Rh-positive blood. Administration of the Rhogam prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.
- Options A and B are not related to the Rh incompatibility.
- Option D is not indicated for the administration of Rhogam.
4. Answer: A. Naloxone (Narcan). Opioid analgesics are prescribed for to pregnant women who are experiencing moderate to severe labor pains. Respiratory depression may occur as a sign of opioid toxicity. Naloxone (Narcan) is an opioid antagonist, which reverses the effects of opioid toxicity such as respiratory depression.
- Options B, C, and D are opioid analgesic.
5. Answer A. Ischemic heart disease. Methergine (Methylergonovine maleate) is a semi-synthetic ergot alkaloid used for the prevention and control of postpartum hemorrhage. Ergot alkaloids are contraindicated in patients with cardiovascular diseases such as ischemic heart disease, stroke, peripheral vascular disease, rheumatic heart disease.
- Options B, C, and D are not contraindicated with the use of methergine.
6. Answer: C. “The vitamin K will protect the newborn from bleeding.” Vitamin K is administered to the newborn in order to prevent bleeding disorders. Vitamin K promotes the formation of clotting factors II, VII, IX & X in which the infants lack because of insufficient intestinal bacteria needed for synthesizing fat-soluble vitamin K.
- Option A: Vitamin K does not promote the development of immunity.
- Option B: Vitamin K does not prevent the occurrence of hyperbilirubinemia.
- Option D: Vitamin K doesn’t prevent the newborn from having jaundice or anemia.
7. Answer: D. Uterine hyperstimulation. Oxytocin is used to induce labor by stimulating uterine contraction. Oxytocin infusion must be discontinued if any signs of uterine stimulation are present.
- Option A: Eary decelerations of the fetal heart rate are a reassuring sign, but it does not indicate fetal distress.
- Options B and C are probably caused by the labor experience itself.
8. Answer: C. Betamethasone (Celestone). Glucocorticoids such as betamethasone and dexamethasone are being used to increase the production of surfactant to aid in fetal lung maturation. It is being given to patients who are in preterm labor at 28-32 weeks of gestation if the labor can be stopped for 2 days.
- Option A, B, and D are opioid analgesic.
9. Answer: C. Random blood sugar. Elevation of blood glucose level is expected for patients receiving corticosteroid therapy such as dexamethasone so a routine check on the sugar level must be monitor.
- Option A: Instead of Red blood cell count, White blood cell count must be monitor for any signs of infection, because corticosteroid suppresses the immune system.
- Options B and D are not related to the use of dexamethasone.
10. Answer: B. Grade 1. Grade 1 pertains to sluggished or diminished response.
- Option A: refers to no response.
- Option C: refers to active or expected response.
- Option D: refers to brisk, hyperactive, with intermittent or transient clonus.
11. Answer: C. Blood pressure. Methylergonovine causes uterine contractions and can elevate the blood pressure, so the priority assessment for the nurse to take is to check the blood pressure first.
- Options A, B, and D are part of postpartum assessment but does not specifically relate to the administration of the medication.
12. Answer: A. Intratracheal. Lung surfactant is instilled through the catheter inserted into the newborn‘s endotracheal tube.
- Options B, C, and D are not the routes of administration for this medication.
13. Answer B. Given intramuscularly in the lateral aspect of the middle third of the vastus lateralis muscle. Rubella Vaccine is administered subcutaneously prior hospital discharge to a nonimmune postpartum client.
- Option A: Common side effects on the injection site.
- Option C: The client should avoid pregnancy for 1 to 3 months after immunization with rubella vaccine.
- Option D: The possible presence of egg protein in the vaccine.
14. Answer A. Have the client hold void before administration. Dinoprostone is a prostaglandin use in the induction of labor. It is administered vaginally so in order for the medication not to be contaminated with urine, the nurse should let the client void before administration.
- Options B, C, and D are the correct nursing interventions.
15. Answer: B, C, and E. The presence of hypertonic contractions indicates the need to initiate emergency measures. The oxytocin infusion must be stopped to reduce uterine stimulation, administering oxygen will promote increased fetal and maternal oxygenation.
- Option A: The nurse should stay with the client.
- Option D: Placing the client in a supine position will not promote an increase in placental oxygenation.