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 ["A","C","D"]

Explanation

A. Weight loss: Severe and prolonged nausea/vomiting leads to weight loss (>5% of pre-pregnancy weight). This is a key feature of hyperemesis gravidarum.

B. Abdominal cramping: Hyperemesis gravidarum does not cause abdominal cramping. Cramping is more associated with miscarriage, ectopic pregnancy, or gastrointestinal conditions.

C. Severe vomiting: Persistent, severe vomiting is the hallmark sign of hyperemesis gravidarum. It is much more severe than typical morning sickness and leads to dehydration and nutritional deficiencies.

D. Electrolyte imbalance: Prolonged vomiting leads to dehydration and loss of essential electrolytes (e.g., hypokalemia, hyponatremia, metabolic alkalosis).

E. Vaginal blood spotting: Hyperemesis gravidarum does not cause vaginal bleeding. Vaginal spotting could indicate a miscarriage or another obstetric complication.

A. Blood pressure reading is at the prenatal baseline. B. Dependent edema has resolved. C. Urinary output has increased. D. The client complains of a headache and blurred vision.

Correct Answer is D

Explanation

A. Blood pressure reading is at the prenatal baseline. If blood pressure remains stable, it does not indicate worsening preeclampsia.

B. Dependent edema has resolved. A decrease in edema suggests an improvement, not worsening, of preeclampsia.

C. Urinary output has increased. Decreased urinary output is concerning in preeclampsia, while increased output suggests better kidney function.

D. The client complains of a headache and blurred vision. These are signs of severe preeclampsia, indicating possible cerebral edema or hypertensive crisis, which requires immediate medical attention.

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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

A nurse is assessing a client at 10 weeks of gestation who has been diagnosed with hyperemesis gravidarum. Which of the following manifestations should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is D

Explanation

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