A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia.
Which of the following findings should the nurse report to the provider?
Headache for 30 min
Fetal heart rate 158/min
Respirations 16/min
Urinary output 40 mL in 2 hr
The Correct Answer is D
Rationale:
A. Headache can be a common side effect of magnesium sulfate but is usually not concerning unless severe or persistent.
B. A fetal heart rate of 158/min is within the normal range for a fetus and is not typically associated with magnesium sulfate administration.
C. Respirations of 16/min are within the normal range and are not typically associated with magnesium sulfate administration.
D. A urinary output of 40 mL in 2 hours is significantly reduced and may indicate magnesium toxicity or impaired renal function, which should be reported to the provider for further
evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A heart rate of 130/min is elevated and may indicate continued dehydration or stress. It does not necessarily indicate the effectiveness of oral rehydration therapy.
B. A capillary refill greater than 3 seconds indicates poor perfusion and ongoing dehydration. It does not indicate the effectiveness of oral rehydration therapy.
C. A respiratory rate of 24/min is within normal range for a 3-year-old child. It does not necessarily indicate the effectiveness of oral rehydration therapy.
D. A urine specific gravity of 1.015 indicates adequate hydration. Normal urine specific gravity typically ranges from 1.005 to 1.030, and a value closer to 1.015 indicates proper hydration
status. Therefore, this finding suggests that oral rehydration therapy has been effective in restoring fluid balance.
Correct Answer is C
Explanation
Rationale:
A. While covering the cord with a sterile, moist saline dressing is important, it is not the first priority when the umbilical cord is prolapsed.
B. While preparing for an immediate birth may become necessary, the first action should be to relieve pressure on the cord to prevent cord compression and compromise to fetal circulation.
C. This is the priority action to prevent cord compression and maintain fetal oxygenation.
D. Placing the client in the knee-chest position can help relieve pressure on the cord, but the nurse's immediate action should be to manually support the cord while awaiting further
instructions from the healthcare provider.
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