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(A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.

(A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of 21 is considered a normal tendon reflex; 3+ is considered brisker than normal. (B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing. (C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium. Urinary output of <100 mL in a 4-hour period may result in toxic levels of magnesium. (D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical syndrome for which magnesium sulfate is frequently used in medical management. Protein in the urine is not induced by magnesium sulfate intake.

(A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.

(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.