You Selected: Prepare the woman for birth Correct response: Ask what time this happened and note the color, amount, and odor of the fluid Rationale: Gather more information. Noting the color, amount, and odor of the fluid, as well as the time of rupture, will help guide the nurse in her next action. There’s no need to immediately call the client’s provider or prepare this client for birth if the fluid is clear and birth isn’t imminent. Rupture of membranes isn’t unusual in the early stages of labor. Fluid collection for microbial analysis is not routine if there’s no concern for infection. Question 27 A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate IV for three hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing, blood pressure of 150/100 mmHg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min, and urine output of 20 ml/hr. Which action would be most appropriate?
You Selected: Continue monitoring per standards of care Correct response: Stop the magnesium sulfate infusion Rationale: Magnesium sulfate should be withheld if the client’s respiratory rate or urine output falls, or if reflexes are diminished or absent, all of which are true for this client. The client also shows other signs of impending toxicity, such as flushing and feeling warm. Inaction will not resolve the client’s suppressed DTRs, low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down. Question 28 A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for one minute. What is the nurse’s priority intervention? You Selected: Place the mother on her left side and apply oxygen Correct response: Place the mother on her left side and apply oxygen Rationale: An FHR below 70 beats/minute is considered severe fetal bradycardia, and immediate interventions are needed. The nurse would first apply oxygen after positioning the mother on her left side. Positioning the mother in the lithotomy position is not indicated. Although the provider would be notified of the status change in the client, the nurse would not wait on orders from the provider to act. Slowing the IV rate would reduce the circulating volume of blood and worsen the problem. Question 29 A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? You Selected: Monitor fetal heart tones Correct response: Monitor fetal heart tones Rationale: Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the