A nurse is evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate.
Which of the following findings should the nurse report to the provider as a sign of fetal compromise?
Fetal heart rate of 140 beats/min
Fetal movement of 10 times in an hour
Oligohydramnios on ultrasound
Reactive nonstress test
The Correct Answer is C
Oligohydramnios on ultrasound. Oligohydramnios is a condition where the amniotic fluid volume is less than expected for gestational age. It can be a sign of fetal compromise due to various causes, such as renal abnormalities, placental insufficiency, premature rupture of membranes, or chromosomal anomalies. Oligohydramnios can lead to complications such as fetal deformities, preterm birth, infection, or stillbirth.
Choice A is wrong because a fetal heart rate of 140 beats/min is within the normal range for most of pregnancy.
Choice B is wrong because fetal movement of 10 times in an hour is also within the normal range and indicates fetal well-being.
Choice D is wrong because a reactive nonstress test is a reassuring sign that the fetus is not hypoxic or stressed.
Normal ranges:
• Amniotic fluid index (AFI): 5-25 cm
• Fetal heart rate: 110-160 beats/min
• Fetal movement: at least 10 movements in 2 hours
• Nonstress test: at least two accelerations of fetal heart rate of 15 beats/min for 15 seconds or more in 20 minutes
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client will have to monitor her blood pressure at home for a month after delivery because preeclampsia can persist or develop for the first time after delivery.The client should seek medical care if she has signs of postpartum preeclampsia, such as severe headaches, vision changes, severe belly pain, nausea and vomiting.
Choice A is wrong because magnesium sulfate is an anticonvulsant medication that is given to prevent seizures in women with severe preeclampsia during labor and usually for 24 hours after delivery.
It is not needed for another week.
Choice C is wrong because breastfeeding is not contraindicated in women with preeclampsia.Breastfeeding may even lower the blood pressure and help with bonding.
Choice D is wrong because contraception is not related to preeclampsia.The client should discuss with her healthcare provider about the best contraceptive method for her based on her medical history and preferences.
Correct Answer is A
Explanation
The client has no seizures.Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia and eclampsia.Seizures are a life-threatening complication of eclampsia and indicate a failure of therapy.
Choice B is wrong because diuresis is not a goal of magnesium sulfate therapy.Diuresis may indicate fluid overload or renal impairment, which are complications of preeclampsia and eclampsia.
Choice C is wrong because improved fetal movement is not a direct outcome of magnesium sulfate therapy.Fetal movement may be affected by many factors, such as gestational age, maternal position, and fetal well-being.
Choice D is wrong because increased platelet count is not a result of magnesium sulfate therapy.Platelet count may be decreased in preeclampsia and eclampsia due to disseminated intravascular coagulation, which is a serious complication that requires prompt treatment.
Normal ranges for blood pressure are less than 140/90 mm Hg, for proteinuria are less than 300 mg/24 hours, for platelet count are 150,000 to 400,000/mm3, and for serum magnesium are 1.5 to 2.5 mEq/L.
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