, Question 1
A patient receiving magnesium sulfate for preeclampsia has a serum
magnesium level of 8.2 mg/dL, respiratory rate of 11/min, and absent deep
tendon reflexes. Which is the priority nursing action?
A. Continue the infusion and reassess in 1 hour.
B. Stop the infusion and prepare to administer calcium gluconate.
C. Decrease the infusion rate by 50% and notify the provider.
D. Administer furosemide to enhance magnesium excretion.
Correct Answer: B - Stop the infusion and prepare to administer
calcium gluconate.
RATIONALE
Magnesium level >8 mg/dL with respiratory depression and areflexia
indicates magnesium toxicity; the infusion must be stopped
immediately and calcium gluconate (antidote) given. Continuing or
merely decreasing the rate delays reversal of life-threatening toxicity.
Furosemide is not the antidote and may worsen renal perfusion.
Question 2
A neonate born to a diabetic mother is jittery and has a blood glucose of 32
mg/dL at 1 hour of life. Which action should the nurse take first?
A. Administer 10% dextrose IV bolus.
B. Feed the neonate with breast milk or formula.
C. Recheck glucose in 30 minutes.
D. Place the neonate under a radiant warmer.
Correct Answer: B - Feed the neonate with breast milk or
formula.
Page 2
, RATIONALE
For asymptomatic hypoglycemia (glucose <40 mg/dL) in a neonate,
first-line treatment is early feeding with breast milk or formula to
provide glucose. IV dextrose is reserved for symptomatic or severe
hypoglycemia. Rechecking without intervention delays treatment, and
warming does not correct hypoglycemia.
Question 3
Which assessment finding in a postpartum patient 24 hours after vaginal
delivery requires immediate intervention?
A. Fundus firm at umbilicus, lochia rubra moderate.
B. Perineal edema with 2+ pitting edema.
C. Blood pressure 150/95 mmHg and severe headache.
D. Hemoglobin 10.5 g/dL and heart rate 90/min.
Correct Answer: C - Blood pressure 150/95 mmHg and severe
headache.
RATIONALE
Severe headache with hypertension at 24 hours postpartum is a
warning sign of postpartum preeclampsia, which can progress to
eclampsia; immediate evaluation and magnesium sulfate may be
needed. The other findings are within normal postpartum variations
and do not require immediate intervention.
Question 4
A pediatric patient receiving digoxin for heart failure has a heart rate of 80 bpm
and serum potassium of 3.2 mEq/L. Which action is most appropriate?
A. Administer the scheduled digoxin dose.
B. Hold digoxin and notify the provider.
C. Administer potassium supplement and give digoxin.
D. Recheck heart rate in 1 hour before giving digoxin.
Correct Answer: B - Hold digoxin and notify the provider.
Page 3
, RATIONALE
Hypokalemia increases the risk of digoxin toxicity; the heart rate of 80
bpm in a child may be bradycardic depending on age, but the critical
issue is the low potassium. Digoxin should be held and the provider
notified for evaluation. Administering potassium without an order is
not independent nursing action.
Question 5
A nurse is calculating the dose of intravenous immunoglobulin (IVIG) for a
child with Kawasaki disease. The order is 2 g/kg over 10 hours. The child
weighs 20 kg. What is the correct total dose?
A. 20 g
B. 40 g
C. 60 g
D. 80 g
Correct Answer: B - 40 g
RATIONALE
The dose is 2 g/kg × 20 kg = 40 g. This is the standard high-dose IVIG
regimen for Kawasaki disease to reduce coronary artery aneurysm
risk. Other options reflect miscalculations.
Question 6
Which statement by a parent of a child with sickle cell disease indicates a need
for further teaching?
A. I will give ibuprofen for pain at home.
B. I will encourage my child to drink plenty of fluids.
C. I will apply cold packs to painful areas.
D. I will bring my child to the clinic for a fever.
Correct Answer: C - I will apply cold packs to painful areas.
Page 4
A patient receiving magnesium sulfate for preeclampsia has a serum
magnesium level of 8.2 mg/dL, respiratory rate of 11/min, and absent deep
tendon reflexes. Which is the priority nursing action?
A. Continue the infusion and reassess in 1 hour.
B. Stop the infusion and prepare to administer calcium gluconate.
C. Decrease the infusion rate by 50% and notify the provider.
D. Administer furosemide to enhance magnesium excretion.
Correct Answer: B - Stop the infusion and prepare to administer
calcium gluconate.
RATIONALE
Magnesium level >8 mg/dL with respiratory depression and areflexia
indicates magnesium toxicity; the infusion must be stopped
immediately and calcium gluconate (antidote) given. Continuing or
merely decreasing the rate delays reversal of life-threatening toxicity.
Furosemide is not the antidote and may worsen renal perfusion.
Question 2
A neonate born to a diabetic mother is jittery and has a blood glucose of 32
mg/dL at 1 hour of life. Which action should the nurse take first?
A. Administer 10% dextrose IV bolus.
B. Feed the neonate with breast milk or formula.
C. Recheck glucose in 30 minutes.
D. Place the neonate under a radiant warmer.
Correct Answer: B - Feed the neonate with breast milk or
formula.
Page 2
, RATIONALE
For asymptomatic hypoglycemia (glucose <40 mg/dL) in a neonate,
first-line treatment is early feeding with breast milk or formula to
provide glucose. IV dextrose is reserved for symptomatic or severe
hypoglycemia. Rechecking without intervention delays treatment, and
warming does not correct hypoglycemia.
Question 3
Which assessment finding in a postpartum patient 24 hours after vaginal
delivery requires immediate intervention?
A. Fundus firm at umbilicus, lochia rubra moderate.
B. Perineal edema with 2+ pitting edema.
C. Blood pressure 150/95 mmHg and severe headache.
D. Hemoglobin 10.5 g/dL and heart rate 90/min.
Correct Answer: C - Blood pressure 150/95 mmHg and severe
headache.
RATIONALE
Severe headache with hypertension at 24 hours postpartum is a
warning sign of postpartum preeclampsia, which can progress to
eclampsia; immediate evaluation and magnesium sulfate may be
needed. The other findings are within normal postpartum variations
and do not require immediate intervention.
Question 4
A pediatric patient receiving digoxin for heart failure has a heart rate of 80 bpm
and serum potassium of 3.2 mEq/L. Which action is most appropriate?
A. Administer the scheduled digoxin dose.
B. Hold digoxin and notify the provider.
C. Administer potassium supplement and give digoxin.
D. Recheck heart rate in 1 hour before giving digoxin.
Correct Answer: B - Hold digoxin and notify the provider.
Page 3
, RATIONALE
Hypokalemia increases the risk of digoxin toxicity; the heart rate of 80
bpm in a child may be bradycardic depending on age, but the critical
issue is the low potassium. Digoxin should be held and the provider
notified for evaluation. Administering potassium without an order is
not independent nursing action.
Question 5
A nurse is calculating the dose of intravenous immunoglobulin (IVIG) for a
child with Kawasaki disease. The order is 2 g/kg over 10 hours. The child
weighs 20 kg. What is the correct total dose?
A. 20 g
B. 40 g
C. 60 g
D. 80 g
Correct Answer: B - 40 g
RATIONALE
The dose is 2 g/kg × 20 kg = 40 g. This is the standard high-dose IVIG
regimen for Kawasaki disease to reduce coronary artery aneurysm
risk. Other options reflect miscalculations.
Question 6
Which statement by a parent of a child with sickle cell disease indicates a need
for further teaching?
A. I will give ibuprofen for pain at home.
B. I will encourage my child to drink plenty of fluids.
C. I will apply cold packs to painful areas.
D. I will bring my child to the clinic for a fever.
Correct Answer: C - I will apply cold packs to painful areas.
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