Custom: NSG 135 Exam #3 Spring 2025

Explanation

The correct answer is:

D. Persistent vomiting that prevents fluid intake

Explanation for the correct answer:

• Persistent vomiting that prevents fluid intake is a warning sign that can indicate hyperemesis gravidarum, a condition that may cause dehydration, electrolyte imbalance, and weight loss. It is a more severe form of nausea and vomiting during pregnancy and requires medical attention to prevent complications for both the mother and fetus.
  

Why the other options are incorrect:

• A. Increased urination, especially at night
  
  • Increased urination, especially at night, is a common and normal symptom in pregnancy, particularly in the first trimester. It is typically due to hormonal changes and increased blood flow to the kidneys. It does not require calling the clinic unless it is associated with other symptoms like pain or burning.
    
• B. Occasional mild headaches relieved with rest
  
  • Mild headaches are common in the first trimester due to hormonal changes, increased blood volume, and changes in blood pressure. If headaches are mild and relieved by rest, they are not typically a cause for concern. However, persistent or severe headaches may require further evaluation.
    
• C. Breast tenderness and enlargement
  
  • Breast tenderness and enlargement are normal symptoms in the first trimester due to hormonal changes in pregnancy. These symptoms are generally not alarming and are part of the physiological changes the body undergoes in preparation for lactation.
    

Correct Answer Is:

Persistent vomiting that prevents fluid intake is a serious concern and could indicate hyperemesis gravidarum, which requires medical intervention. The other symptoms listed, while uncomfortable, are typically normal in the first trimester and do not warrant immediate concern.

Explanation

Explanation for the correct answer:
A respiratory rate of 8 breaths per minute is a critical sign of magnesium sulfate toxicity. Magnesium sulfate is a central nervous system depressant, and one of the earliest signs of toxicity is respiratory depression (typically defined as a respiratory rate below 12 breaths per minute). A rate of 8 indicates significant depression of the respiratory system and requires immediate intervention, such as stopping the magnesium infusion and preparing to administer calcium gluconate, the antidote for magnesium toxicity.

Why the other options are incorrect:

B. Urine output of 60 mL in the past two hours
This output is below the expected threshold (minimum 30 mL/hr or 60 mL/2 hr), suggesting reduced renal perfusion or possible renal impairment. While it is concerning, it does not require immediate intervention in the same urgent manner as respiratory depression. However, it should be monitored closely because reduced urine output can lead to accumulation of magnesium, increasing the risk of toxicity.

C. Deep tendon reflexes of +2
This is a normal finding. Magnesium sulfate can depress deep tendon reflexes, and loss or significant reduction (e.g., 0 or +1) is an early sign of toxicity. A +2 reflex indicates that the magnesium level is likely within a therapeutic range.

D. Complaints of mild nausea and flushing
These are common and expected side effects of magnesium sulfate therapy, especially during the loading dose. These symptoms are not dangerous and do not require immediate action.

Summary:

The correct answer is A. Respiratory rate of 8 breaths per minute because it is a life-threatening sign of magnesium sulfate toxicity and requires immediate intervention. The other findings—low but not critically low urine output, normal deep tendon reflexes, and mild flushing/nausea—are either expected or not immediately dangerous. Early identification and response to respiratory depression are critical to prevent severe complications, including respiratory arrest.

Explanation

Explanation for the Correct Answer:

D. Intrauterine growth restriction (IUGR)
Smoking during pregnancy is strongly associated with intrauterine growth restriction (IUGR), where the fetus does not grow at a normal rate in the uterus. The toxins in cigarette smoke can reduce the oxygen and nutrients that reach the fetus, which can impair fetal growth and development. This can lead to low birth weight and other complications, such as preterm birth and placental issues.

Why the Other Options Are Incorrect:

A. Congenital heart defects
While smoking during pregnancy may increase the risk for various birth defects, including congenital heart defects, it is not the primary complication associated with smoking. The risk for IUGR is more directly linked to smoking than the risk for heart defects.

B. Hearing loss
Smoking during pregnancy is not directly linked to an increased risk of hearing loss in the newborn. Hearing loss can result from various factors, but smoking is not a primary risk factor for this condition.

C. Type 1 diabetes mellitus
Type 1 diabetes is an autoimmune condition that typically develops in childhood and is not directly related to maternal smoking during pregnancy. Smoking does not increase the risk of Type 1 diabetes in the newborn.

Correct Answer Is:

The correct answer is D. Intrauterine growth restriction (IUGR). Smoking during pregnancy is most commonly associated with IUGR, as it restricts oxygen and nutrient supply to the fetus, leading to impaired growth. The other complications listed are not primarily associated with smoking during pregnancy.

Explanation

D. Increased blood volume
During pregnancy, there is an increase in blood volume to supply oxygen and nutrients to both the mother and fetus. This increase can lead to increased pressure in the veins, particularly in the legs, due to the expanding uterus compressing veins in the pelvis. The increased blood volume and pressure can cause the veins in the legs to become engorged and distended, leading to the development of varicose veins. Additionally, the relaxation of blood vessel walls due to the hormone progesterone contributes to the condition.

Why the Other Options Are Incorrect:

A. Reduced cardiac output
Cardiac output typically increases during pregnancy, not decreases. This increase in cardiac output helps ensure adequate blood flow to both the mother and the fetus. Reduced cardiac output would be more concerning for conditions like heart failure, not varicose veins.

B. Dehydration leading to poor circulation
While dehydration can cause circulation issues, it is not the primary contributor to varicose veins during pregnancy. The primary factor is the increase in blood volume and the physical changes in the circulatory system due to pregnancy.

C. Decreased progesterone levels
Progesterone actually increases during pregnancy, not decreases. Progesterone helps relax smooth muscle tissue, including the veins, which can contribute to the development of varicose veins. However, the overall increase in blood volume plays a more significant role in the development of varicose veins than a change in progesterone levels.

Summary:

The correct answer is D. Increased blood volume. The primary factor contributing to varicose veins during pregnancy is the increase in blood volume, which puts more pressure on the veins, especially in the legs. This increased pressure, combined with hormonal changes, contributes to the development of varicose veins.

Explanation

Explanation for the Correct Answers:

A. Keep calcium gluconate readily available.
Magnesium sulfate is being administered to prevent seizures in a client with severe preeclampsia. In case of magnesium toxicity, calcium gluconate is the antidote. It should be readily available to reverse any signs of toxicity, such as respiratory depression or absent deep tendon reflexes.

B. Check urinary output every 2 hr.
Monitoring urinary output is important when administering magnesium sulfate, as it can cause renal impairment. Checking output every 2 hours helps detect any signs of kidney dysfunction or magnesium toxicity.

C. Check deep tendon reflexes every 1 hr.
Magnesium sulfate can cause hyporeflexia (reduced reflexes) in case of toxicity. The nurse should check deep tendon reflexes every 1 hour to monitor for signs of magnesium toxicity, which can manifest as absent reflexes.

E. Report respiratory rate of less than 12 breaths/min to the provider.
A respiratory rate of less than 12 breaths per minute is a sign of magnesium toxicity, which can cause respiratory depression. If this occurs, the nurse should immediately report it to the provider, as respiratory failure may follow.

Why the Other Option is Incorrect:

D. Provide intermittent fetal monitoring.
Continuous fetal monitoring is more appropriate for this client due to the high-risk nature of the pregnancy and the administration of magnesium sulfate. Intermittent fetal monitoring would not provide sufficient real-time data on fetal well-being.

Correct Answer Is:

The correct answers are A, B, C, and E. The nurse should keep calcium gluconate available, monitor urinary output and deep tendon reflexes frequently, and report a respiratory rate of less than 12 breaths per minute. Continuous fetal monitoring is preferred over intermittent monitoring.

Explanation

The correct answer is:

B. Placenta previa

Explanation for the Correct Answer:

B. Placenta previa

• Placenta previa occurs when the placenta is positioned low in the uterus and covers or is near the cervix. It is characterized by painless, bright red vaginal bleeding in the second or third trimester, which matches the client’s symptoms (recent onset of bright red vaginal bleeding without uterine contractions or tenderness). The absence of uterine tenderness and normal fetal heart rate also points towards placenta previa.
  

Why the Other Options are Incorrect:

A. Preterm labor

• Preterm labor is associated with regular uterine contractions, cervical changes, and sometimes vaginal bleeding. The client does not have uterine contractions, which makes preterm labor less likely in this case.
  

C. Placental abruption

• Placental abruption involves the premature separation of the placenta from the uterine wall, which typically presents with painful, dark red vaginal bleeding and uterine tenderness. The client’s presentation, which includes a soft, non-tender uterus, does not align with this condition.
  

D. Vasa previa

• Vasa previa occurs when fetal blood vessels cross or run near the cervical os, which can lead to fetal bleeding and fetal distress during labor. It is often accompanied by sudden, severe fetal heart rate decelerations, which are not present in this case. Also, the bleeding in vasa previa is typically associated with labor or rupture of membranes.
  

Correct Answer Is:

The most likely condition based on the client's symptoms (bright red vaginal bleeding without uterine tenderness or contractions and normal fetal heart rate) is B. Placenta previa.

Explanation

Potential Condition: Pyelonephritis

Rationale:
The client is presenting with symptoms indicative of pyelonephritis, which include bilateral flank pain, urinary frequency, dysuria, chills, nausea, and fever (temperature of 39.2°C or 102.6°F). The urinalysis shows positive leukocyte esterase, positive nitrites, and the presence of WBCs, which all point to a urinary tract infection. Given the fever and systemic symptoms, this infection has likely ascended to the kidneys, causing pyelonephritis.

Actions to Take:

1. Administer ceftriaxone as prescribed:
   
   • Ceftriaxone is an appropriate antibiotic for treating pyelonephritis during pregnancy. It targets the infection and helps prevent complications such as sepsis or preterm labor.
     
2. Assess for signs of sepsis:
   
   • Sepsis can develop from an untreated or inadequately treated pyelonephritis, especially in the setting of pregnancy. The nurse should assess for tachycardia, hypotension, and worsening fever, as these are signs of sepsis.
     

Parameters to Monitor:

1. Urine output:
   
   • Monitoring urine output is essential for assessing the effectiveness of the antibiotic treatment and ensuring that the kidneys are functioning well despite the infection.
     
2. Uterine contractions:
   
   • Pyelonephritis during pregnancy can increase the risk of preterm labor. The nurse should monitor for any uterine contractions as this could indicate labor or infection-related uterine irritation.
     

Summary:

The most likely diagnosis is pyelonephritis, given the client’s symptoms and the diagnostic results. The priority actions for the nurse include administering ceftriaxone and assessing for signs of sepsis. Monitoring urine output and uterine contractions are essential to track the client’s progress and ensure a favorable outcome for both mother and fetus.

Explanation

The correct answer is:

A. It prevents the formation of Rh antibodies in mothers who are Rh negative.

Explanation for the correct answer:

• Rh(D) immunoglobulin is administered to Rh-negative mothers to prevent the formation of Rh antibodies. When an Rh-negative mother carries an Rh-positive baby, there is a risk of her immune system producing antibodies against Rh-positive blood cells (a process called sensitization). The Rh(D) immunoglobulin prevents the mother's immune system from producing these antibodies, thus protecting future pregnancies from Rh incompatibility.
  

Why the other options are incorrect:

• B. It destroys Rh antibodies in mothers who are Rh negative.
  
  • This is incorrect. Rh(D) immunoglobulin does not destroy antibodies but prevents the formation of Rh antibodies. If antibodies have already been formed, the immunoglobulin is not effective.
    
• C. It prevents the formation of Rh antibodies in newborns who are Rh positive.
  
  • This is incorrect. The Rh(D) immunoglobulin is administered to the mother, not the newborn, to prevent the formation of antibodies in the mother. It does not affect the newborn's immune system directly.
    
• D. It destroys Rh antibodies in newborns who are Rh positive.
  
  • This is incorrect. Rh(D) immunoglobulin is not intended to destroy antibodies in newborns. It is administered to the mother to prevent the development of antibodies that could affect future pregnancies, not to treat the newborn.
    

Correct Answer Is:

Rh(D) immunoglobulin is given to Rh-negative mothers to prevent the formation of Rh antibodies in the mother, which helps prevent complications in future pregnancies with Rh-positive infants.

Explanation

The correct answer is:

100 gtt/min

Explanation for the Correct Answer:

To calculate the IV flow rate in gtt/min, use the formula:

Flow rate (gtt/min) = Volume to be infused (mL) ÷ Time (min) × Drop factor (gtt/mL)

In this case:

• Volume to be infused = 100 mL
  
• Time = 60 minutes (since 1 hour = 60 minutes)
  
• Drop factor = 60 gtt/mL
  

Now, plugging in the values:

Flow rate = 100 mL ÷ 60 min × 60 gtt/mL

Flow rate = 100 ÷ 60 × 60

Flow rate = 100 gtt/min

Why the other answers are incorrect:

There are no other options provided, but it's important to note that using the correct formula and values is critical for accurate IV flow rate calculation.

Correct Answer Is:

The IV flow rate should be set to 100 gtt/min.