ATI Real Life 4.0 RN Maternal Newborn Preclampsia

Nurse Morgan is preparing to administer hydralazine 5 mg IV bolus. Available is hydralazine 20 mg/mL. How many mL should Morgan administer? (Round the answer to the nearest hundredth.)

0.25

Nurse Morgan is reviewing Klein lab test result. Which of the following finding should Morgan discuss with Klein regarding her worsening condition (Preclampsia)

Increased Proteinuria

Nurse Morgan is administering IV magnesium sulfate to Ms. Klein. Which of the following manifestations indicates Ms. Klein is experiencing magnesium toxicity?

Respiration 11/min

Nurse Morgan is preparing to administer magnesium sulfate IV at 2 g/ hr. Available is magnesium sulfate 40 g/1,000 mL lactated Ringer's. Morgan should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)

50ml/hr

Nurse Morgan is preparing to teach Ms. Klein about delivery by cesarean section. Which of the following should Morgan include in the teaching? Select all that apply. a) you will receive pain medication following the procedure b) your spouse will give informed consent c) monitoring of the fetal heart will continue d) you will receive antiemetic medications e) I will review options for anesthesia with you

ACD

Nurse Morgan reviews the laboratory test results for Ms. Klein. Which of the following findings confirms a diagnosis of severe preeclampsia?

Aspartate aninotransferase AST 75 units/L

Nurse Morgan recognizes Ms. Klein is experiencing variable decelerations of the fetal heart rate. Which of the following nursing interventions should Morgan take at this time?

Change Klein Position

Nurse Morgan prepares to call Dr. Hunt and give a report. Which of the following is the most important clinical data for Morgan to include in the SBAR report?

Elevated BP

SBAR

SBAR: S = Situation: 25 year-old female, gravida 1 para 0, at 27 weeks gestation. Came to the ED this morning at 0800. B = Background: Reports sudden weight gain, and a new onset of nausea & vomiting, also blurred vision and headache. Says she had breakfast earlier this morning but that she vomited soon after eating. A = Assessment: Vital Signs: T37.0, P 92, R 22, BP 162/88, 02 sat 97%, urine protein 1 +, deep tendon reflexes 3+, reports right upper quadrant pain, nausea and vomiting and blurred vision with a headache. R = Recommendation: transfer to maternal newborn unit.

Nurse Morgan completes an admission assessment for Ms. Klein. Based on the assessment, which of the following is the priority nursing intervention at this time

initiate seizure precautions

Nurse Morgan is reviewing prescriptions from Dr.Hunt. For which of the following should she plan to monitor the following of hydralazine ( Apresoline)

Tachycardia