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 A
Explanation
A. Glucose
Rationale:
A. Glucose monitoring is essential for clients with polycystic ovarian syndrome (PCOS) due to the increased risk of insulin resistance and diabetes.
B. Blood urea nitrogen (BUN) levels are not typically monitored specifically for PCOS.
C. Thyroid-stimulating hormone (TSH) levels may be assessed if there is suspicion of thyroid dysfunction but are not routinely monitored for PCOS.
D. Liver function tests are not typically indicated for routine monitoring in PCOS unless there are specific signs or symptoms of liver dysfunction.
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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