A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia.
Which of the following findings should the nurse report to the provider?
Headache for 30 min
Fetal heart rate 158/min
Respirations 16/min
Urinary output 40 mL in 2 hr
The Correct Answer is D
Rationale:
A. Headache can be a common side effect of magnesium sulfate but is usually not concerning unless severe or persistent.
B. A fetal heart rate of 158/min is within the normal range for a fetus and is not typically associated with magnesium sulfate administration.
C. Respirations of 16/min are within the normal range and are not typically associated with magnesium sulfate administration.
D. A urinary output of 40 mL in 2 hours is significantly reduced and may indicate magnesium toxicity or impaired renal function, which should be reported to the provider for further
evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Green penile discharge is not a typical finding in genital herpes. Discharge associated with genital herpes is usually clear or cloudy and may be accompanied by pain or itching.
B. Influenza-like symptoms, such as fever, headache, muscle aches, and fatigue, are common manifestations of genital herpes. However, they are not specific to the condition and can occur with various viral infections.
C. Anuria, or the absence of urine production, is not associated with genital herpes. It is a symptom of renal dysfunction or urinary tract obstruction.
D. White- or flesh-colored papillary growths in the genital area, known as genital warts or condylomata acuminata, are a characteristic finding of genital herpes caused by HSV 2. These growths are typically painless but can cause itching or discomfort.
Correct Answer is A
Explanation
A. "I'll let my baby drain one breast at each feeding."
Rationale:
A. "I'll let my baby drain one breast at each feeding." This statement indicates understanding because allowing the baby to empty one breast at each feeding helps in relieving breast engorgement by effectively removing milk. It promotes better milk flow and prevents overproduction.
B. Feeding the baby every 2 hours is a common recommendation, but it may not specifically address breast engorgement management.
C. Cold compresses can help reduce discomfort from engorgement, but they should be applied after feeding, not before.
D. While herbal teas can sometimes provide relief for engorgement, this statement does not address the direct management of engorgement through breastfeeding techniques.
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