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.
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Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should anticipate a provider prescription for an antiviral medication, as evidenced by the client's presentation of small pinpoint open vesicles and pustules on the labia majora, which are indicative of a herpes simplex virus infection, a common cause of genital ulcers. The clear drainage and absence of pain are consistent with this diagnosis. Additionally, the thick, mucopurulent discharge could suggest a secondary bacterial infection, for which the provider may prescribe antibiotics.
Antiviral medication is likely prescribed for perineal lesions because these can be indicative of a viral infection, such as herpes. The nurse should recognize the need for antivirals to manage and treat the underlying cause.
Correct Answer is D
Explanation
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.
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