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.
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Related Questions
Correct Answer is C
Explanation
Fetal heart rate decelerations indicate a possible compromise of fetal oxygenation and should be reported to the provider immediately.Decelerations can be caused by various factors such as cord compression, uterine hyperstimulation, maternal hypotension, or placental abruption.
Choice A is wrong because a fetal heart rate of 140 beats per minute is within the normal range of 110 to 160 beats per minute.
Choice B is wrong because uterine contractions every 10 minutes are not abnormal in a client with severe pre-eclampsia who is receiving magnesium sulfate.Magnesium sulfate is used to prevent seizures and lower blood pressure in pre-eclampsia, but it does not stop labor.
Choice D is wrong because uterine contractions lasting 60 seconds are not a sign of …
Correct Answer is A
Explanation
Choice A rationale: Magnesium sulfate acts as a central nervous system depressant. In HELLP syndrome and preeclampsia, its primary therapeutic purpose is to provide seizure prophylaxis by decreasing neuromuscular irritability and excitability.
Choice B rationale: While magnesium sulfate may cause slight vasodilation, it is not an antihypertensive agent. Elevated blood pressure in HELLP syndrome is managed with specific medications like hydralazine, labetalol, or nifedipine.
Choice C rationale: Magnesium sulfate does not function as a diuretic. In fact, adequate urine output is a critical assessment for magnesium toxicity, as the medication is primarily excreted by the kidneys.
Choice D rationale: Magnesium sulfate has no direct effect on bone marrow or platelet production. HELLP syndrome is characterized by low platelets; improvement usually only occurs following delivery or resolving the underlying condition.
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