a nurse is assisting with the care of a client who is receiving iv magnesium sulfate which of the following medications should the nurse anticipate ad
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Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam

1. A healthcare professional is assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the healthcare professional anticipate administering if magnesium sulfate toxicity is suspected?

Correct answer: D

Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity. In cases of magnesium sulfate toxicity, calcium gluconate is administered to counteract the effects of magnesium and restore calcium levels. Magnesium toxicity can lead to symptoms such as muscle weakness, respiratory depression, and cardiac arrhythmias. Calcium gluconate helps in reversing these effects by competing with magnesium and preventing its adverse manifestations. Nifedipine is a calcium channel blocker used for conditions like hypertension and angina, not for magnesium toxicity. Pyridoxine is vitamin B6 and is not the antidote for magnesium toxicity. Ferrous sulfate is an iron supplement and is not used to treat magnesium sulfate toxicity.

2. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?

Correct answer: B

Rationale: The priority action for the nurse in this situation is to position the client with one hip elevated. This position can help improve blood flow to the placenta and stabilize blood pressure, which is crucial for both the client and the fetus during labor. It can also help optimize fetal oxygenation by improving circulation. Notifying the provider of the findings may be necessary, but ensuring proper positioning of the client takes precedence to address the immediate physiological needs. Asking the client about pain medication or having the client void are important interventions but are not the priority in this scenario where the client is experiencing painful contractions and has low blood pressure.

3. A caregiver is learning about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Dressing a baby in flame-retardant clothing is crucial to prevent injuries, especially in case of accidental exposure to fire sources. This safety measure can provide an added layer of protection for the newborn. The other options do not directly address newborn safety concerns or best practices. Option B focuses on keeping clothing dry, which is not a primary safety concern. Option C poses a risk of overheating the formula, which can be dangerous for the baby. Option D, covering the crib mattress with plastic, may pose a suffocation hazard to the baby.

4. A client who is at 24 weeks of gestation is scheduled for a 1-hour glucose tolerance test. Which of the following statements should the nurse include in her teaching?

Correct answer: C

Rationale: The correct statement to include in the teaching for a client scheduled for a 1-hour glucose tolerance test at 24 weeks of gestation is that a blood glucose level of 130 to 140 mg/dL is considered a positive screening result. This range indicates a potential issue with glucose metabolism and would prompt the need for a follow-up 3-hour glucose tolerance test to confirm the diagnosis of gestational diabetes mellitus. Choices A, B, and D are incorrect. In a 1-hour glucose tolerance test, the glucose solution is typically consumed within a specific timeframe before the test, not necessarily 1 hour prior. There is usually no specific requirement to limit carbohydrate intake for 24 hours prior to the test. Fasting for 8 hours prior to the test is more common for a fasting glucose test, not a 1-hour glucose tolerance test.

5. A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?

Correct answer: B

Rationale: When a newborn is transferred to the nursery, the first action the nurse should take is to verify the newborn's identification. This step is crucial for ensuring the correct care is provided to the right newborn, promoting patient safety and preventing errors. Administering vitamin K (Choice C) is important but should not be the first action. Determining obstetrical risk factors (Choice D) is not the priority when the newborn is transferred to the nursery. Confirming (Choice A) and verifying (Choice B) have similar meanings, but 'verify' is a more appropriate term in this context.

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