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

Deep tendon reflexes (DTR)

Creatinine

client denies pain

Vaginal exam

Blood pressure

Decreased sensation in legs

Answer and Explanation

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

A. Deep tendon reflexes (DTR) – Worsening

On 2/10, the client had hyperreflexia (DTRs 3+) and no clonus. By 2/11, the DTRs had increased to 4+ with positive clonus, indicating neuromuscular hyperexcitability, a hallmark of worsening preeclampsia with severe features. Clonus is a concerning sign that suggests progression toward eclampsia (seizures). This indicates neurological worsening.

B. Creatinine – Worsening

The client's creatinine level increased from 1.4 mg/dL (already elevated) to 2.0 mg/dL, which is indicative of worsening renal function. Normal pregnancy should not cause a creatinine rise above 1.1 mg/dL, so this elevation suggests renal impairment due to severe preeclampsia. The worsening creatinine level indicates deteriorating kidney function, possibly due to reduced renal perfusion.

C. Client denies pain – Unrelated

The absence of pain is not directly related to the client’s condition worsening or improving. While pain can be a symptom of severe preeclampsia (such as epigastric pain from liver involvement), the client currently has an epidural, which can explain the lack of pain perception. The denial of pain does not indicate improvement in the disease process but rather effective pain management.

D. Vaginal exam – Improvement

The vaginal exam findings indicate progress in labor. On 2/10, the client was not noted to be in active labor, but by 2/11, she was 7 cm dilated, 80% effaced, and at 0 station, with contractions increasing in frequency and intensity. This progression suggests that labor is advancing appropriately.

E. Blood pressure – Worsening

The client’s blood pressure was severely elevated on 2/10 (168/100 mmHg) and remained high on 2/11 (152/86 mmHg). While slightly lower, the diastolic remains elevated, and systolic pressures are still high. Given the worsening DTRs, renal function decline, and elevated liver enzymes, the blood pressure changes are not a sign of improvement but rather persistent hypertension despite possible interventions.

F. Decreased sensation in legs – Unrelated

The client received an epidural for pain relief, which normally causes decreased sensation in the lower extremities. This finding is not related to worsening preeclampsia or labor progression but is an expected effect of the epidural anesthesia. The client’s ability to slightly move her legs confirms that the block is working properly.

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Correct Answer is C

Explanation

A. "We will monitor your blood pressure to see if it decreases."
While magnesium sulfate may have a mild antihypertensive effect, it is not primarily given to lower blood pressure; antihypertensives are used for that purpose.

B. "We will check for a reduction in swelling and fluid retention."
Edema in preeclampsia is due to capillary leakage and kidney dysfunction, not directly affected by magnesium sulfate.

C. "We will assess for a decrease in seizure activity and improved reflexes."
Magnesium sulfate is used primarily as a seizure prophylaxis in preeclampsia by stabilizing the central nervous system and reducing hyperreflexia and clonus, which are signs of worsening preeclampsia.

D. "You should feel less pain and have fewer headaches."
While magnesium sulfate can improve symptoms, it is not an analgesic and does not directly relieve pain.

A. Fetal heart rate (FHR) B. Bowel sounds C. Respiratory rate D. Temperature

Correct Answer is C

Explanation

A. Fetal heart rate (FHR): While FHR monitoring is important, the priority is assessing the mother's respiratory status due to the risk of magnesium toxicity, which can lead to respiratory depression.

B. Bowel sounds: Magnesium sulfate can cause decreased gastrointestinal motility, but bowel sounds are not the immediate priority. The nurse should monitor for paralytic ileus, but respiratory function takes precedence.

C. Respiratory rate: Magnesium sulfate is a central nervous system (CNS) depressant that can cause respiratory depression if levels become too high. A respiratory rate below 12 breaths per minute is a sign of magnesium toxicity, requiring immediate intervention (e.g., stopping the infusion and administering calcium gluconate).

D. Temperature: Temperature is not directly affected by magnesium sulfate administration, making it a lower-priority assessment compared to respiratory rate.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving magnesium sulfate for severe preeclampsia. The client asks, "How will I know if the medication is working?" Which response by the nurse is most appropriate?

Correct Answer is C

Explanation

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is C

Explanation

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