A nurse is assessing a client at 34 weeks' gestation who is receiving magnesium sulfate to treat preeclampsia. Which of the following findings should the nurse report to the provider?
Blood Pressure 120/90
Respiratory rate 16
Fetal heart rate baseline 158/min
Urinary output 40 mL in 2 hours
The Correct Answer is D
A. A blood pressure of 120/90 mm Hg is not an unexpected finding in a client with preeclampsia receiving treatment. While the diastolic pressure is slightly elevated, it is not severe and does not indicate magnesium toxicity or an urgent complication requiring immediate provider notification.
B. A respiratory rate of 16 breaths per minute is within the normal adult range (12–20/min). Respiratory depression is a key sign of magnesium sulfate toxicity and is typically defined as a respiratory rate below 12/min. Therefore, this finding is not concerning.
C. A fetal heart rate baseline of 158/min is within the upper limit of the normal range (110–160/min). Magnesium sulfate can cause minimal fetal heart rate changes, but this value does not indicate fetal distress and does not require provider notification.
D. Magnesium sulfate is excreted by the kidneys, and adequate urine output is essential to prevent magnesium toxicity. The expected minimum urine output is at least 30 mL/hr. A urine output of 40 mL over 2 hours (20 mL/hr) indicates oliguria and impaired magnesium excretion, increasing the risk for toxicity. This is an abnormal and potentially dangerous finding that must be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Eliciting the Moro reflex to wake the baby is unsafe and unnecessary. This method involves startling the infant, which can cause distress and may result in injury to the nipple, infant’s gums, or palate. It does not address the correct technique for breaking suction safely.
B. Pulling the breast or nipple directly from the baby’s mouth can lead to significant nipple trauma, including cracking, bleeding, and pain, and may also injure the infant’s mouth. This method is considered unsafe and is strongly discouraged in breastfeeding education.
C. Breaking the suction by gently inserting a clean finger into the corner of the infant’s mouth is the recommended technique. This action releases the latch safely, prevents nipple trauma, and allows the infant to unlatch without discomfort. It ensures that both the mother and baby remain safe during breastfeeding, and it supports proper feeding practices.
D. Relying on a popping sound as an indicator of safe breast removal is unreliable and can be misleading. Attempting to remove the breast based on sound alone may result in abrupt or forceful removal, causing pain or injury to the mother’s nipple and the infant’s oral tissues.
Correct Answer is B
Explanation
A. While preterm infants are at increased risk for hypoglycemia due to limited glycogen stores and immature metabolic regulation, dexamethasone does not directly prevent hypoglycemia. Its pharmacologic action is not related to neonatal blood sugar management.
B. Dexamethasone is a corticosteroid given to pregnant clients at risk of preterm birth, typically between 24 and 34 weeks gestation. The medication crosses the placenta and stimulates fetal lung epithelial cells to produce surfactant, a substance that reduces alveolar surface tension, enabling the lungs to remain open for effective gas exchange after birth. By accelerating lung development, dexamethasone significantly reduces the risk of respiratory distress syndrome (RDS), intraventricular hemorrhage, necrotizing enterocolitis, and neonatal mortality. The most benefit is observed when delivery occurs 24–48 hours after the first dose but within 7 days of administration.
C. While corticosteroid therapy can have secondary benefits, including a reduction in intraventricular hemorrhage, this is not the primary purpose of dexamethasone administration. The main goal remains enhancing fetal lung maturity.
D. Dexamethasone is not a tocolytic and does not suppress preterm labor contractions. Tocolytic medications, such as magnesium sulfate, nifedipine, or indomethacin, are used for short-term suppression of uterine activity to allow time for corticosteroids to enhance fetal lung maturity.
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