A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders.
Which of the following orders requires clarification?
Assess deep tendon reflexes every hour
Continuous fetal monitoring
Ambulate twice daily
Obtain a daily weight
The Correct Answer is C
Choice A rationale
Assessing deep tendon reflexes every hour is a common practice in managing severe preeclampsia. Hyperreflexia can be a sign of worsening pre-eclampsia.
Choice B rationale
Continuous fetal monitoring is typically recommended for patients with severe pre-eclampsia. This allows for early detection of fetal distress.
Choice C rationale
Ambulating twice daily may not be appropriate for a patient with severe pre-eclampsia at 35 weeks of gestation. Bed rest is often recommended to help lower blood pressure and reduce the risk of complications.
Choice D rationale
Obtaining a daily weight is a common practice in managing severe pre-eclampsia. Sudden weight gain can be a sign of worsening pre-eclampsia.
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Correct Answer is D
Explanation
Step 1 is to calculate the total amount of Magnesium sulfate in the solution. This is done by multiplying the amount of Magnesium sulfate per mL (which is 50g/L or 0.05g/mL) by the total volume of the solution (which is 1000mL). So, 0.05g/mL × 1000mL = 50g.
Step 2 is to calculate the rate of the IV pump. The maintenance dose is 2g/hr. So, if there are 50g in 1000mL, then 2g would be in (2g ÷ 50g) × 1000mL = 40mL. Therefore, the IV pump should be set at 40 mL/hr.
Correct Answer is D
Explanation
Choice A rationale
Hypomagnesemia, or low magnesium levels, is not typically a primary concern for newborns of mothers with diabetes mellitus. While it can occur, it is not the priority focus of care.
Choice B rationale
Hyperbilirubinemia, or high bilirubin levels, can lead to jaundice in newborns. However, it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.
Choice C rationale
Hypocalcemia, or low calcium levels, can occur in newborns, but it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.
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