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 C
Explanation
Rationale:
A. Weak pulses are not typically associated with a large patent ductus arteriosus. Instead, bounding pulses may be observed due to increased blood flow to the lower extremities.
B. Chronic hypoxemia may occur in some cases of patent ductus arteriosus, but it is not a specific manifestation typically associated with this condition.
C. Systolic murmur is a common finding in newborns with a large patent ductus arteriosus. This murmur is often continuous with the second heart sound and may be heard best at the left upper sternal border.
D. Cyanosis with crying is not typically associated with patent ductus arteriosus. Cyanosis may occur in other cardiac defects but is not a specific finding for patent ductus arteriosus.
Correct Answer is D
Explanation
Rationale:
A. Preterm delivery: While preterm delivery can result in low birth weight, it is not typically considered a direct cause of being small for gestational age (SGA). SGA infants are generally small because of intrauterine growth restriction rather than preterm birth.
B. Fetal hyperinsulinemia: Fetal hyperinsulinemia may lead to macrosomia (large for gestational age) rather than SG
A.
C. Perinatal asphyxia: Perinatal asphyxia refers to oxygen deprivation around the time of birth and is not typically associated with SG
A.
D. Placental insufficiency: Placental insufficiency, resulting in poor nutrient and oxygen transfer to the fetus, is a common cause of SG
A. Insufficient placental function can limit fetal growth,
leading to a newborn being small for their gestational age.
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