A nurse is triaging four clients on the labor and delivery unit.
Which of the following actions should be a priority for nursing care?
Check the blood sugar of a gestational diabetic.
Assess the vaginal blood loss of a client who is recovering from a spontaneous abortion.
Assess the patellar reflexes of a client with pre-eclampsia without severe features.
Check the fetal heart rate of a client whose membranes just ruptured.
The Correct Answer is D
Choice A rationale
Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.
Choice B rationale
Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.
Choice C rationale
Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.
Choice D rationale
Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.
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Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 18 breaths/min is normal and does not indicate magnesium toxicity or the need for calcium gluconate.
Choice B rationale
Urinary output of 30 mL/hr is within the acceptable range and does not suggest magnesium toxicity. This indicates adequate renal function.
Choice C rationale
Patellar reflexes rated at one indicate mild hyporeflexia, which can be a side effect of magnesium sulfate but does not necessitate immediate intervention.
Choice D rationale
Serum magnesium level of 10 mg/dL is significantly elevated, indicating magnesium toxicity. Calcium gluconate is the antidote for magnesium toxicity and should be administered
promptly to prevent severe complications.
Correct Answer is A
Explanation
Choice A rationale
PTB is the leading cause of neonatal mortality and for antenatal hospitalization. This is accurate because preterm birth (PTB) is a significant cause of infant mortality and often
requires extended hospital stays for the management of complications.
Choice B rationale
PTBs result in increased numbers of neonatal and infant deaths and long-term neurological impairment. This is accurate because preterm births are associated with higher rates of
mortality and long-term health issues in infants.
Choice C rationale
PTL is defined as regular uterine contractions resulting in cervical changes before 37 weeks gestation. This is accurate because preterm labor (PTL) is indeed characterized by these
symptoms occurring before full-term pregnancy.
Choice D rationale
Average costs for premature/low birthweight infants are more than 10 times as high than for other newborns. This is accurate because medical care for premature and low
birthweight infants is significantly more expensive due to the need for specialized care and extended hospital stays.