a nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate iv at 2 ghr which of the following findings indicates th
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Nursing Elites

ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. A client with severe preeclampsia is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe to continue the infusion?

Correct answer: B

Rationale: A respiratory rate of 16/min within the normal range is an essential parameter to monitor when administering magnesium sulfate, as respiratory depression is a potential adverse effect. Diminished deep-tendon reflexes may indicate magnesium toxicity, warranting immediate intervention. A urine output of 50 mL in 4 hours is below the expected amount, suggesting decreased kidney perfusion, which can be exacerbated by magnesium sulfate. A heart rate of 56/min is bradycardic and may indicate magnesium toxicity, requiring assessment and possible discontinuation of the infusion.

2. A woman at 38 weeks of gestation and in early labor with ruptured membranes has an oral temperature of 38.9�C (102�F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct answer: C

Rationale: In a pregnant woman with a temperature of 38.9�C (102�F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.

3. A client who is 2 hours postpartum following a cesarean birth has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

Correct answer: D

Rationale: The correct intervention for a client who is 2 hours postpartum following a cesarean birth with a history of thromboembolic disease is to have the client ambulate. Early ambulation is crucial in preventing complications such as deep vein thrombosis in postpartum clients. Applying warm, moist heat, massaging the legs, or placing pillows under the knees do not directly address the risk of thromboembolic disease in this scenario.

4. A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. Following an examination, the provider informs the client that the fetus has died, indicating a:

Correct answer: B

Rationale: A missed miscarriage, also known as a silent or delayed miscarriage, occurs when the embryo or fetus has died, but no bleeding or contractions have occurred to expel it from the uterus. In this scenario, the client's experiencing slight occasional vaginal bleeding over the past two weeks indicates a missed miscarriage as the fetus has died, but the body has not recognized the loss or expelled the products of conception.

5. A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?

Correct answer: A

Rationale: Respiratory acidosis is characterized by an increase in carbon dioxide levels in the blood, leading to acidosis. This condition can affect the heart's electrical conduction system, resulting in widened QRS complexes on an electrocardiogram (ECG). Hyperactive deep tendon reflexes, bounding peripheral pulses, and warm, flushed skin are not typically associated with respiratory acidosis.

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