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 A
Explanation
A. Parity: In GPTAL (Gravida, Parity, Term, Abortions, Living children), "P" refers to parity, which indicates the number of pregnancies carried to 20 weeks or beyond, regardless of outcome.
B. Postpartum: "Postpartum" refers to the period after childbirth and is not part of the GPTAL system.
C. Primigravida: Primigravida refers to a woman who is pregnant for the first time, which is represented by "G" (Gravida) in GPTAL, not "P."
D. Presentation: "Presentation" refers to the fetal part entering the birth canal first (e.g., cephalic, breech) and is unrelated to GPTAL.
Correct Answer is B
Explanation
A. To stimulate uterine contractions: Terbutaline is a tocolytic (a medication that relaxes the uterus), not a uterotonic. It is not used to stimulate contractions.
B. To improve placental blood flow: Terbutaline relaxes uterine muscles, decreasing contraction frequency and intensity, thereby improving placental blood flow. It is often used in intrauterine resuscitation when there is uteroplacental insufficiency and fetal distress due to excessive contractions (tachysystole).
C. To decrease fetal heart rate variability: Terbutaline does not directly affect fetal heart rate variability. It is used to reduce uterine contractions, which can secondarily improve fetal oxygenation.
D. To prevent preterm labor: While terbutaline can be used to delay preterm labor, in this context, it is being used for intrauterine resuscitation, not for preventing labor.
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