a nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous iv infusion which of the following findings shoul

HESI LPN

HESI Focus on Maternity Exam

1. A client with preeclampsia is receiving magnesium sulfate by continuous IV infusion. Which finding should the nurse report to the provider?

A. Blood pressure 148/94 mm Hg
B. Respiratory rate 14/min
C. Urinary output 20 mL/hr
D. 2+ deep tendon reflexes

Correct answer: C

Rationale: In a client with preeclampsia receiving magnesium sulfate, a urinary output of 20 mL/hr is a concerning finding as it may indicate renal impairment or magnesium toxicity. Adequate urinary output is crucial for eliminating excess magnesium and preventing toxicity. The nurse should report this finding to the provider for further evaluation. A blood pressure of 148/94 mm Hg is elevated but expected in a client with preeclampsia. A respiratory rate of 14/min is within the normal range. 2+ deep tendon reflexes are a common finding in clients receiving magnesium sulfate and are not a cause for concern unless they progress to hyperreflexia or clonus.

2. Genotypes are solely based on genetic information.

A. TRUE
B. FALSE
C. Sometimes
D. Never

Correct answer: B

Rationale: The correct answer is B - FALSE. Genotypes are solely based on genetic information and do not reflect environmental influences. Phenotypes, on the other hand, result from the interaction of genetic and environmental factors. Choices A, C, and D are incorrect because genotypes are not influenced by environmental factors, and they are determined by an individual's genetic makeup.

3. Which of the following statements is true of Down’s syndrome?

A. Down’s syndrome is usually caused by an extra copy of chromosome 21 in an individual.
B. The symptoms of Down’s syndrome are similar to those of sickle-cell anemia.
C. Down’s syndrome is caused by a sexually transmitted infection (STI) during conception.
D. The probability of having a child with Down’s syndrome increases with the age of the parents.

Correct answer: D

Rationale: The correct answer is D. The likelihood of having a child with Down’s syndrome increases as the age of the parents increases, particularly the mother's age. Choice A is incorrect because Down’s syndrome is caused by an extra copy of chromosome 21, not a defect in the sex chromosomes. Choice B is incorrect as the symptoms of Down’s syndrome and sickle-cell anemia are different. Choice C is also incorrect as Down’s syndrome is not caused by a sexually transmitted infection during conception.

4. When obtaining a health history from a client, a nurse in a woman’s health clinic should identify which of the following findings as increasing the client’s risk for developing pelvic inflammatory disease (PID)?

A. Recurrent Cystitis
B. Frequent Alcohol Use
C. Use of Oral Contraceptives
D. Chlamydia Infection

Correct answer: D

Rationale: Chlamydia infection is a significant risk factor for developing pelvic inflammatory disease (PID). PID is often caused by untreated sexually transmitted infections (STIs) like Chlamydia and Gonorrhea that ascend from the vagina to the upper reproductive organs. Recurrent cystitis (choice A) is more related to urinary tract infections, frequent alcohol use (choice B) is not directly linked to PID, and the use of oral contraceptives (choice C) does not increase the risk of developing PID.

5. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?

A. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.”
B. “The drug keeps your baby from requiring too much sedation.”
C. “Surfactant is used to reduce episodes of periodic apnea.”
D. “Your baby needs this medication to fight a possible respiratory tract infection.”

Correct answer: A

Rationale: Artificial surfactant can be administered as an adjunct to oxygen and ventilation therapy for premature infants with respiratory distress syndrome (RDS). It helps improve respiratory compliance by aiding in the exchange of oxygen and carbon dioxide until the infant can produce enough surfactant naturally. The correct explanation to the parents would be that surfactant therapy enhances the baby’s lung function by facilitating the exchange of oxygen and carbon dioxide. Choice B is incorrect because surfactant therapy does not affect sedation needs. Choice C is inaccurate as surfactant is not used to reduce episodes of periodic apnea. Choice D is incorrect as surfactant is not administered to fight respiratory tract infections; it specifically targets improving lung function in RDS.