A nurse is monitoring a client who is receiving magnesium sulfate to manage preeclampsia.
Which of the following observations should the nurse immediately report to the healthcare provider?
The client’s respiratory rate is 16/min.
The client has had a headache for 30 minutes.
The client’s urinary output is 40 ml in 2 hours.
The client’s fetal heart rate is 158/min.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: A respiratory rate of 16/min is within the normal range for an adult and does not indicate immediate concern.
Choice B rationale: A headache can be a symptom of preeclampsia, but it is not as immediate a concern as the other options unless it is severe or accompanied by other symptoms.
Choice C rationale: A urinary output of 40 ml in 2 hours is significantly below the normal range. Oliguria (low urine output) can be a sign of renal impairment and magnesium toxicity, which requires immediate reporting to the healthcare provider.
Choice D rationale: A fetal heart rate of 158/min is within the normal range for a fetus and does not indicate immediate concern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While seeing a counselor could be beneficial for some women experiencing doubts and second thoughts about their pregnancy, suggesting this as an initial response may make the client feel that her feelings are abnormal or require professional help.
Choice B rationale
Asking if the client has spoken to her mother about these feelings assumes that the client has a good relationship with her mother or that her mother is available for support, which may not be the case.
Choice C rationale
Telling the client not to worry and that she will be fine once the baby is born may minimize her feelings and does not acknowledge her current emotional state.
Choice D rationale
Ambivalent feelings are quite common for women early in pregnancy. This response validates the client’s feelings and reassures her that what she is experiencing is normal.
Correct Answer is A
Explanation
Choice A rationale
Painless vaginal bleeding at 28 weeks of gestation can be a sign of placenta previa or placental abruption, both of which are serious conditions that require immediate attention.
Choice B rationale
While vaginal spotting after a missed period could indicate early pregnancy, it is not as immediately concerning as painless vaginal bleeding in the third trimester.
Choice C rationale
Nausea and vomiting at 14 weeks of gestation are common symptoms of early pregnancy and, while uncomfortable, are not usually a medical emergency.
Choice D rationale
A cough and fever at 38 weeks of gestation could indicate an infection, which should be evaluated. However, it is not as immediately concerning as painless vaginal bleeding in the third trimester.
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