A nurse is assessing a client who is receiving magnesium sulfate as a treatment for preeclampsia. Which of the following clinical findings is the nurse's priority?

Urinary output 40 mL in 2 hr

Fetal heart rate 158/min

Reflexes +2

Respirations 16/min

Answer and Explanation

The Correct Answer is A

A. Urinary output 40 mL in 2 hr: Oliguria (urine output < 30 mL/hr) is a sign of magnesium toxicity, which can lead to respiratory depression, loss of reflexes, and cardiac arrest. The kidneys excrete magnesium, and impaired renal function increases toxicity risk. This finding requires immediate action.

B. Fetal heart rate 158/min: A fetal heart rate of 158 bpm is within the normal range (110-160 bpm) and is not a priority concern.

C. Reflexes +2: A +2 reflex response is normal. In magnesium toxicity, reflexes become diminished or absent (+1 or 0), indicating neuromuscular depression.

D. Respirations 16/min: While respiratory depression is a concern with magnesium sulfate, a respiratory rate of 16 breaths/min is within normal limits (12-20 bpm) and does not require immediate intervention. However, monitoring is still necessary.

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Correct Answer is D

Explanation

A. Antenatal steroid administration: Antenatal steroids (e.g., betamethasone) are used to enhance fetal lung maturity in preterm pregnancies (<34 weeks). At 35 weeks, steroids are generally not indicated.

B. Expectant management protocols: Expectant management (delaying delivery with close monitoring) is considered in mild preeclampsia but is not appropriate in severe preeclampsia due to the risk of maternal and fetal complications.

C. Method of birth: The method of birth (vaginal vs. C-section) is determined based on maternal and fetal conditions. While important, it is not the key consideration in addressing the client's concern about their birth plan.

D. Shared decision-making: Shared decision-making ensures that the client feels heard and involved in their care plan, even in urgent situations. The nurse should acknowledge the client's concerns, explain the rationale for induction, and explore possible accommodations for their birth plan.

A. 3+ protein in the urine B. 1+ pitting sacral edema C. Blood pressure 148/98 mm Hg D. Deep tendon reflexes of +1

Correct Answer is D

Explanation

A. 3+ protein in the urine: Severe proteinuria (≥2+ on dipstick) is a diagnostic criterion for preeclampsia. The presence of 3+ proteinuria is consistent with preeclampsia.

B. 1+ pitting sacral edema: Edema is common in preeclampsia, especially in dependent areas like the hands, face, and sacral region. This is not inconsistent with preeclampsia.

C. Blood pressure 148/98 mm Hg: Preeclampsia is defined as blood pressure ≥140/90 mm Hg after 20 weeks of gestation, with proteinuria or other signs of organ dysfunction. A BP of 148/98 mm Hg is consistent with preeclampsia.

D. Deep tendon reflexes of +1: Hyperreflexia (+3 or +4 reflexes) is a common finding in preeclampsia due to neuromuscular irritability. A +1 reflex response indicates diminished reflexes, which is not characteristic of preeclampsia.

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A nurse is assessing a client who is receiving magnesium sulfate as a treatment for preeclampsia. Which of the following clinical findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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