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Based on the client's assessment on 2/11 at 1200, indicate if the client's condition is improving, worsening or not related based on the condition.

A.

Blood pressure

B.

Deep tendon reflexes (DTR)

C.

Vaginal exam (client denies pain)

D.

Decreased sensation in legs

E.

Creatinine

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

  1. Blood pressure (Worsening):

    • Elevated or worsening blood pressure can indicate the progression of hypertension or a related condition, such as preeclampsia. It’s a serious sign that needs immediate attention.

  2. Deep tendon reflexes (DTR) (Worsening):

    • Increased or hyperactive deep tendon reflexes often indicate an abnormal neurological or medical condition, such as preeclampsia or nervous system distress. This worsening could signal a more severe condition, needing further evaluation.

  3. Vaginal exam (client denies pain) (Unrelated):

    • The absence of pain during a vaginal exam may not be directly related to the client’s overall worsening or improving condition. It’s neutral in terms of contributing to any significant changes in the client’s condition.

  4. Decreased sensation in legs (Worsening):

    • A worsening loss of sensation in the legs can suggest a neurological issue, such as nerve compression or even complications from a vascular condition. This condition is concerning, as it indicates progression and requires immediate investigation.

  5. Creatinine (Worsening):

    • Elevated creatinine levels are a marker of kidney dysfunction or damage. If creatinine levels are worsening, it indicates a decline in kidney function, which could be a sign of renal failure or preeclampsia and needs urgent attention.


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Related Questions

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale

Assisting the patient onto her left side can improve uteroplacental perfusion by relieving pressure on the vena cava, potentially improving fetal oxygenation and addressing fetal heart rate decelerations. This position maximizes blood flow to the uterus and placenta.

Choice B rationale

A vaginal examination is crucial to assess for umbilical cord prolapse, especially in the presence of fetal heart rate decelerations or bradycardia. Prolapse of the cord can severely compromise fetal oxygen supply, necessitating immediate intervention.

Choice C rationale

Discontinuing the oxytocin infusion is essential if fetal heart rate abnormalities occur, as oxytocin stimulates uterine contractions, which can further compromise fetal oxygenation if the fetus is already stressed. Reducing or stopping contractions can alleviate fetal distress.

Choice D rationale

Administering oxygen at 10 L/min via nonrebreather face mask increases the maternal oxygen supply, which in turn can increase the oxygen available to the fetus across the placenta. This is a standard intervention for fetal distress.

Choice E rationale

Notifying the health care provider is a critical step to communicate the fetal heart rate abnormalities and the interventions implemented. The provider can then assess the situation, determine the underlying cause, and order further management.

Choice F rationale

Stopping the magnesium sulfate is indicated primarily for signs of magnesium toxicity in the mother, such as respiratory depression, loss of deep tendon reflexes, or decreased urine output. While magnesium sulfate can affect the fetus, it is not a first-line intervention for fetal heart rate abnormalities unless related to preterm labor management.

Correct Answer is B

Explanation

Choice A rationale

While fetal heart rate (FHR) is a crucial assessment in preterm labor, especially when considering the effects of medications, it is not the immediate priority assessment before initiating magnesium sulfate. Magnesium sulfate primarily affects the mother's central nervous system and neuromuscular system.

Choice B rationale

Respiratory rate is the priority nursing assessment before administering magnesium sulfate. Magnesium sulfate is a central nervous system depressant and can cause respiratory depression, a potentially life-threatening side effect. Establishing a baseline respiratory rate and ensuring it is within the normal range (12-20 breaths per minute for adults) is critical before administering the medication.

Choice C rationale

Temperature is an important vital sign to monitor, but it is not the priority assessment before administering magnesium sulfate. Magnesium sulfate does not typically have a direct impact on body temperature. Other assessments related to the medication's effects take precedence. Normal adult temperature range is typically 97.8°F to 99.1°F (36.5°C to 37.3°C).

Choice D rationale

Bowel sounds are an assessment related to gastrointestinal function and are not the priority assessment before administering magnesium sulfate. While magnesium sulfate can have some effects on smooth muscle, including the intestines, the immediate risk of respiratory depression necessitates prioritizing respiratory assessment. Normal bowel sounds are typically described as normoactive, with clicks and gurgles occurring irregularly.

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