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 B
Explanation
Rationale:
A. Smiles when a parent appears: This is a social and emotional developmental milestone typically achieved by an 8-month-old infant and is not indicative of cerebral palsy.
B. Sits with pillow props: Difficulty sitting without support or requiring props to maintain a sitting position can be a manifestation of cerebral palsy, reflecting motor delays and impaired muscle control.
C. Tracks an object with eyes: Tracking objects with eyes is a visual developmental milestone and does not directly relate to cerebral palsy.
D. Uses a pincer grasp to pick up a toy: The pincer grasp typically develops around 9 to 12 months of age and is not directly related to cerebral palsy.
Correct Answer is C
Explanation
Rationale:
A. Increasing the rate of infusion of IV oxytocin could exacerbate the uterine hyperstimulation and fetal decelerations, potentially leading to fetal distress. It is not appropriate in this situation.
B. Slowing the client's rate of breathing would not address the issue of fetal decelerations caused by uterine hyperstimulation. This action is not relevant to the situation described.
C. Discontinuing the infusion of the IV oxytocin is the correct action in this scenario. The presence of uniform decelerations beginning at the peak of contractions suggests uterine hyperstimulation, likely caused by oxytocin. Discontinuing the oxytocin infusion allows the uterus to rest, reducing the risk of further fetal distress.
D. Decreasing the rate of infusion of the maintenance IV solution is not the priority in this
situation. The issue is uterine hyperstimulation caused by oxytocin, so discontinuing the oxytocin infusion is the appropriate action to take.
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