A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

Increased fetal movement

Increased respiratory rate

Increased muscle weakness

Increased urinary output

Answer and Explanation

The Correct Answer is C

The correct answer is choice C, "Increased muscle weakness." The nurse should instruct the client to report increased muscle weakness, as this can indicate toxicity from magnesium sulfate. Increased fetal movement is not an indication of toxicity from magnesium sulfate. Increased respiratory rate is a common side effect of magnesium sulfate and does not require intervention unless it is significantly increased. Increased urinary output is a normal effect of magnesium sulfate and does not require intervention.

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Correct Answer is C

Explanation

A. Discomfort in the lower back (sacral area) is common during labor, particularly during contractions. This is not an unusual finding that would require immediate reassessment.

B. Contractions lasting between 45 to 60 seconds are typical during the active phase of labor. This duration of contractions is expected as labor progresses, and does not require immediate reassessment.

C. This sensation can indicate that the fetus has descended into the birth canal and may be a sign that the client is entering the second stage of labor, or is close to delivery. This requires immediate reassessment by the nurse to check for full cervical dilation and fetal descent.

D. Emotional excitement and changes in skin temperature are typical responses during labor due to the physiological and emotional aspects of childbirth. This does not indicate the need for immediate reassessment.

A. Scant lochia B. Temperature 37.4° C (99.3° F) C. Uterine tenderness D. WBC Count 9,000/mm²

Correct Answer is C

Explanation

The correct answer is choice C: Uterine tenderness. Endometritis is an infection of the endometrial lining of the uterus. Uterine tenderness is a common finding in clients with endometritis.

Choice A, scant lochia, and choice D, WBC count 9,000/mm², are not typical findings in clients with endometritis. Choice B, temperature 37.4° C (99.3° F), is within the normal range and may not be indicative of endometritis.

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A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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