A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)
Evaluate fetal heart rate and contraction patterns.
Obtain prescription to repeat hepatic panel.
Monitor for evidence of seizure activity.
Check the urinary output in hourly urinometer.
Inspect the perineum for vaginal bleeding.
Correct Answer : A,B,C,D
Choice A rationale
Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.
Choice B rationale
Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.
Choice C rationale
Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.
Choice D rationale
Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.
Choice E rationale
Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The postpartum period is characterized by leukocytosis, where WBC counts can rise to 30,000/mm³ due to physiological stress. A WBC count of 15,000/mm³ is within the expected range for this client.
Choice B rationale
Perineal hematomas are more likely to cause localized pain and swelling than systemic symptoms. The assessment of perineal area is important but not the first priority in this context.
Choice C rationale
Monitoring temperature, heart rate, and respirations is crucial to identify infection but checking the differential to confirm normal physiological response to postpartum is prioritized first.
Choice D rationale
Notifying the HCP for an elevated WBC count without additional signs of infection is premature. A WBC count of 15,000/mm³ alone is not indicative of an infection in postpartum clients.
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are abrupt decreases in fetal heart rate, unrelated to contractions and typically caused by umbilical cord compression. The described pattern does not match these characteristics.
Choice B rationale
Late decelerations occur when there is a gradual decrease in fetal heart rate starting after the contraction begins and returning to baseline after the contraction ends, often indicating utero-placental insufficiency.
Choice C rationale
No decelerations are present when there are no decreases in fetal heart rate. The scenario described includes a specific pattern of decelerations, making this choice incorrect.
Choice D rationale
Early decelerations are a gradual decrease in fetal heart rate that mirrors the contraction pattern, often caused by head compression during contractions. The pattern described does not fit early decelerations.
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