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 A
Explanation
A. Routine prenatal HIV screening is recommended for all pregnant women, regardless of identified risk factors. Universal testing helps identify undiagnosed HIV early, allowing for timely antiretroviral therapy, which significantly reduces the risk of maternal-to-child transmission. This approach avoids missed diagnoses that can occur when testing is based only on perceived risk.
B. Women with a history of STIs are at increased risk for HIV and should be tested; however, limiting testing only to this group would miss many cases. Therefore, this option is incomplete and not the most appropriate answer.
C. Having multiple sexual partners increases the risk for HIV infection, but prenatal HIV testing is not limited to women with this risk factor. Universal screening is recommended instead.
D. Even women who are monogamous may be at risk if their partner is infected or has other risk factors. For this reason, monogamy does not eliminate the need for prenatal HIV testing.
Correct Answer is D
Explanation
A. Fetal position refers to the relationship of a specific reference point on the fetus (usually the occiput, sacrum, or mentum) to the maternal pelvis, such as left occiput anterior (LOA). It describes how the fetus is oriented in relation to the maternal pelvis, not the relationship of fetal body parts to each other.
B. Fetal lie refers to the longitudinal axis of the fetus in relation to the maternal spine. It can be longitudinal, transverse, or oblique. While important in assessing labor, it does not describe the fetal body parts in relation to each other.
C. Fetal presentation refers to the part of the fetus that enters the maternal pelvis first, such as cephalic (head), breech (buttocks), or shoulder. Presentation does not describe the alignment of fetal body parts relative to each other.
D. Fetal attitude describes the relationship of the fetal body parts to one another, specifically the degree of flexion or extension of the fetal head, arms, and legs. The most common and favorable attitude for labor is general flexion, where the head is flexed, arms and legs are flexed, and the back is curved. This attitude allows the smallest diameter of the fetal head to pass through the birth canal, facilitating vaginal delivery.
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