A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia.
Which of the following observations should the nurse report to the healthcare provider?
Respiratory rate of 16 breaths per minute
Fetal heart rate of 158 beats per minute
Persistent headache for 30 minutes
Urinary output of 40 mL in 2 hours
The Correct Answer is D
Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. In a cephalic (head-down) presentation, fetal heart tones are typically heard below the umbilicus.
B. A posterior position refers to the fetal back facing the mother's back, but it does not affect the heart tone location significantly.
C. A transverse lie would place the fetal heart tones at the lateral sides of the abdomen, not above the umbilicus.
D. In a frank breech position (buttocks presenting first), fetal heart tones are usually heard above the umbilicus, as the fetal head is positioned in the upper uterus.
Correct Answer is D
Explanation
Step 1 is to calculate the volume of betamethasone to be drawn up for each dose. The order is to administer betamethasone IM and to repeat the dose after 2 hours. Betamethasone is available as 4mg/mL. Therefore, to administer a dose of 12mg, the nurse would need to draw up 12mg ÷ 4mg/mL = 3mL for each dose.
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