Maternal Child Nursing Care
7th Edition
Author(s)Shannon Perry
PublisherPublished
by Mosby Copyright© 2023
ISBN: 9780323776714
TEST BANK
Question 1
Multiple Choice
,A pregnant client at 34 weeks' gestation reports a persistent
headache and visual disturbances. Blood pressure is 162/104
mm Hg, urine protein is 3+, and deep tendon reflexes are 3+.
What is the nurse's priority action?
Medium
Options: A. Encourage oral fluids and rest. B. Administer
prescribed magnesium sulfate. C. Reassess blood pressure in 30
minutes. D. Provide a high-protein snack.
Correct Answer: B. Administer prescribed magnesium sulfate.
Rationale: The client demonstrates severe features of
preeclampsia (severe hypertension, headache, visual changes,
proteinuria, hyperreflexia). Magnesium sulfate is indicated to
prevent progression to eclamptic seizures and is the priority
intervention.
Incorrect Options:
1. Oral fluids and rest are supportive measures but do not
address imminent seizure risk.
2. Delaying treatment for 30 minutes is unsafe in severe
preeclampsia.
3. Nutrition is important but not the priority in this acute
situation.
Nursing Process: Implementation
Clinical Judgment: Prioritize hypotheses; take action.
,Bloom's Level: Apply
Question 2
SATA
A client with severe preeclampsia is receiving magnesium
sulfate. Which findings require immediate nursing
intervention? Select all that apply.
Hard
1. Respiratory rate 10/min
2. Urine output 20 mL/hr
3. Patellar reflexes absent
4. Blood pressure 146/92 mm Hg
5. Serum magnesium 9.5 mg/dL
Correct Answers: 1, 2, 3, 5
Rationale: Respiratory depression, oliguria, absent reflexes, and
elevated serum magnesium indicate magnesium toxicity and
require immediate action, including stopping the infusion and
notifying the provider.
Incorrect Option: 4. The blood pressure is elevated but not the
most urgent finding compared with signs of toxicity.
Nursing Process: Assessment and Evaluation
Clinical Judgment: Recognize cues; evaluate outcomes.
Bloom's Level: Analyze
, Question 3
NGN Matrix/Grid
For each finding, indicate whether it is Expected with
magnesium therapy, Concerning for toxicity, or Unrelated.
Hard
Finding Expected Toxicity Unrelated
Warm flushed skin ✓
Absent deep tendon reflexes ✓
Respiratory rate 8/min ✓
Urine output 15 mL/hr ✓
Mild nausea ✓
Rationale
Warmth, flushing, and mild nausea are common effects of
magnesium sulfate. Absent reflexes, respiratory depression,
and oliguria suggest toxic accumulation.
Nursing Process: Assessment
Clinical Judgment: Recognize cues.
Bloom's Level: Analyze
Question 4
Multiple Choice
7th Edition
Author(s)Shannon Perry
PublisherPublished
by Mosby Copyright© 2023
ISBN: 9780323776714
TEST BANK
Question 1
Multiple Choice
,A pregnant client at 34 weeks' gestation reports a persistent
headache and visual disturbances. Blood pressure is 162/104
mm Hg, urine protein is 3+, and deep tendon reflexes are 3+.
What is the nurse's priority action?
Medium
Options: A. Encourage oral fluids and rest. B. Administer
prescribed magnesium sulfate. C. Reassess blood pressure in 30
minutes. D. Provide a high-protein snack.
Correct Answer: B. Administer prescribed magnesium sulfate.
Rationale: The client demonstrates severe features of
preeclampsia (severe hypertension, headache, visual changes,
proteinuria, hyperreflexia). Magnesium sulfate is indicated to
prevent progression to eclamptic seizures and is the priority
intervention.
Incorrect Options:
1. Oral fluids and rest are supportive measures but do not
address imminent seizure risk.
2. Delaying treatment for 30 minutes is unsafe in severe
preeclampsia.
3. Nutrition is important but not the priority in this acute
situation.
Nursing Process: Implementation
Clinical Judgment: Prioritize hypotheses; take action.
,Bloom's Level: Apply
Question 2
SATA
A client with severe preeclampsia is receiving magnesium
sulfate. Which findings require immediate nursing
intervention? Select all that apply.
Hard
1. Respiratory rate 10/min
2. Urine output 20 mL/hr
3. Patellar reflexes absent
4. Blood pressure 146/92 mm Hg
5. Serum magnesium 9.5 mg/dL
Correct Answers: 1, 2, 3, 5
Rationale: Respiratory depression, oliguria, absent reflexes, and
elevated serum magnesium indicate magnesium toxicity and
require immediate action, including stopping the infusion and
notifying the provider.
Incorrect Option: 4. The blood pressure is elevated but not the
most urgent finding compared with signs of toxicity.
Nursing Process: Assessment and Evaluation
Clinical Judgment: Recognize cues; evaluate outcomes.
Bloom's Level: Analyze
, Question 3
NGN Matrix/Grid
For each finding, indicate whether it is Expected with
magnesium therapy, Concerning for toxicity, or Unrelated.
Hard
Finding Expected Toxicity Unrelated
Warm flushed skin ✓
Absent deep tendon reflexes ✓
Respiratory rate 8/min ✓
Urine output 15 mL/hr ✓
Mild nausea ✓
Rationale
Warmth, flushing, and mild nausea are common effects of
magnesium sulfate. Absent reflexes, respiratory depression,
and oliguria suggest toxic accumulation.
Nursing Process: Assessment
Clinical Judgment: Recognize cues.
Bloom's Level: Analyze
Question 4
Multiple Choice
