A nurse receives a shift report and must first assess the high-risk antenatal client who is:
35 weeks gestation with proteinuria and vomiting.
39 weeks gestation with urinary urgency, frequency, and burning.
30 weeks gestation with a fasting blood sugar of 95 mg/dL and a 3-hour glucose of 120.
34 weeks gestation with a hemoglobin of 12 mg/dL and a potassium level of 3.5 mEq/L. .
The Correct Answer is A
Choice A rationale
Proteinuria and vomiting at 35 weeks gestation are significant symptoms that could indicate preeclampsia, a serious condition that requires immediate assessment and management to prevent complications for both the mother and the baby.
Choice B rationale
Urinary urgency, frequency, and burning at 39 weeks gestation suggest a possible urinary tract infection (UTI), which is concerning but generally not as immediately critical as symptoms suggesting preeclampsia.
Choice C rationale
A fasting blood sugar of 95 mg/dL and a 3-hour glucose of 120 at 30 weeks gestation indicate good control of blood sugar levels, which is not as high-risk as preeclampsia symptoms.
Choice D rationale
A hemoglobin of 12 mg/dL and a potassium level of 3.5 mEq/L at 34 weeks gestation are within normal ranges and do not indicate an immediate high-risk condition compared to the potential for preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.8°C (100.3°F) is a low-grade fever that does not typically indicate a serious issue in the context of epidural analgesia during labor. It should be monitored, but it's not immediately concerning.
Choice B rationale
Generalized itching can be a common side effect of epidural analgesia due to the opioids used. It should be monitored and managed, but it does not typically require immediate physician notification.
Choice C rationale
Weakness of the lower extremities can be expected with epidural analgesia as it causes a loss of sensation and muscle control. This should be monitored, but it is not typically an emergency.
Choice D rationale
Fetal bradycardia is a serious concern that must be reported to the physician immediately. It can indicate fetal distress and requires urgent evaluation and intervention to ensure the well-being of the baby. .
Correct Answer is ["A","F","G"]
Explanation
Choice A rationale
Respiratory rate of 8 breaths per minute indicates respiratory depression, a serious adverse effect of magnesium sulfate toxicity. Magnesium sulfate can depress neuromuscular transmission, leading to decreased respiratory effort and rate.
Choice B rationale
Blood pressure of 150/90 mmHg is not indicative of magnesium sulfate toxicity. Elevated blood pressure is a symptom of pre-eclampsia and not directly related to the adverse effects of magnesium sulfate. Therefore, it does not indicate toxicity.
Choice C rationale
Lung crackles are typically associated with fluid overload or heart failure rather than magnesium sulfate toxicity. While it is a serious condition, it is not specifically an adverse effect of magnesium sulfate.
Choice D rationale
Increase in fetal heart rate is not a common adverse effect of magnesium sulfate. Fetal heart rate changes are more commonly related to the underlying maternal condition or other medications used in pregnancy rather than magnesium sulfate.
Choice E rationale
Deep tendon reflexes would typically be decreased or absent in magnesium sulfate toxicity. Therefore, presence of deep tendon reflexes would not indicate an adverse effect of magnesium sulfate.
Choice F rationale
Confusion can occur due to central nervous system depression caused by high levels of magnesium sulfate. This is a significant adverse effect indicating possible toxicity.
Choice G rationale
Urine output of 30 mL in 2 hours suggests oliguria, which can be a sign of magnesium sulfate toxicity as the drug is excreted through the kidneys. Reduced urine output can indicate the kidneys are not clearing the drug efficiently, leading to toxicity.
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