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
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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Related Questions
Correct Answer is D
Explanation
A. Brownish vaginal discharge: Bloody show (pink-tinged mucus) may indicate labor, but brownish discharge alone does not confirm labor. It may indicate old blood or cervical changes.
B. Amniotic fluid in the vaginal vault: The presence of amniotic fluid suggests rupture of membranes, but rupture alone does not confirm active labor unless accompanied by cervical changes.
C. Report of pain above the umbilicus: Labor contractions typically begin in the lower back and radiate to the lower abdomen, not above the umbilicus. Upper abdominal pain may suggest another issue, such as preeclampsia.
D. Cervical dilation: Cervical dilation is the only definitive sign that labor is occurring. True labor involves progressive cervical dilation and effacement due to regular contractions.
Correct Answer is B
Explanation
A. Ciprofloxacin: Ciprofloxacin is a fluoroquinolone, which is contraindicated in pregnancy due to potential adverse effects on fetal cartilage development.
B. Ceftriaxone: Ceftriaxone, a third-generation cephalosporin, is commonly used in pregnancy for pyelonephritis because it is safe and effective against common uropathogens.
C. Amoxicillin: Amoxicillin is not typically the first-line treatment for pyelonephritis because of increasing resistance and less effectiveness against severe infections.
D. Trimethoprim-sulfamethoxazole (TMP-SMX): TMP-SMX is generally avoided in pregnancy, especially in the first trimester (due to neural tube defect risk) and near term (due to kernicterus risk in the newborn).
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