A nurse is assessing the fetal heart rate and uterine activity of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
Which of the following findings should the nurse report to the provider immediately?
Fetal heart rate of 140 beats per minute
Uterine contractions every 10 minutes
Fetal heart rate decelerations
Uterine contractions lasting 60 seconds
The Correct Answer is C
C. Fetal heart rate decelerations.
Fetal heart rate decelerations are temporary drops in the fetal heart rate that can indicate fetal distress or lack of oxygen. There are three types of decelerations: early, late and variable. Early decelerations are benign and caused by compression of the fetus’s head during a uterine contraction. Late decelerations are caused by uteroplacental insufficiency, which is a decrease in blood flow to the placenta. Variable decelerations are the most common type and vary in shape, duration and intensity. They are often caused by cord compression or other factors that affect fetal oxygenation.
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A. Fetal heart rate of 140 beats per minute.
Statement is wrong because this is a normal fetal heart rate. The normal range for fetal heart rate is 120-160 beats per minute.
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B. Uterine contractions every 10 minutes.
Statement is wrong because this is a normal frequency for uterine contractions during early labor.
The normal range for uterine contractions is 5-10 minutes apart.
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D. Uterine contractions lasting 60 seconds.
Statement is wrong because this is a normal duration for uterine contractions during active labor.
The normal range for uterine contractions is 45-90 seconds long.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Answer is A and C. Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension.The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption.The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.
Statement B is wrong because administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.
Statement D is wrong because encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.
Statement E is wrong because assessing for signs of placental abruption is not enough.The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.
Normal ranges for blood pressure are less than 120/80 mmHg for non-pregnant adults and less than 140/90 mmHg for pregnant women.Normal ranges for protein in urine are less than 150 mg/day for non-pregnant adults and less than 300 mg/day for pregnant women.
Correct Answer is C
Explanation
Maintain a dark and quiet environment.This intervention helps to reduce sensory stimulation and prevent seizures in a client with eclampsia.
Choice A is wrong becausemonitoring fetal heart rate and uterine activity continuouslyis not a priority intervention for a client with eclampsia.The priority is to prevent seizures and control blood pressure.
Choice B is wrong becauseadministering oxytocin to augment laboris contraindicated in a client with eclampsia.Oxytocin can increase blood pressure and cause uterine hyperstimulation, which can worsen the condition and endanger the mother and the fetus.
Choice D is wrong becauseencouraging oral fluids and a high-protein dietis not appropriate for a client with eclampsia.
The client should be kept NPO to prevent aspiration in case of a seizure.A high-protein diet can increase the risk of renal failure and hepatic dysfunction.
Choice E is wrong becauseassessing for signs of placental abruptionis not a specific intervention for a client with eclampsia.Placental abruption can occur as a complication of eclampsia, but it is not the main focus of care.
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