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
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.
Correct Answer is C
Explanation
“This medication will help my baby’s lungs develop faster.” Corticosteroid therapy is given to pregnant clients with eclampsia to accelerate fetal lung maturity and reduce the risk of respiratory distress syndrome in the newborn.
Some possible explanations for the other choices are:
• Choice A is wrong because corticosteroids do not lower blood pressure.Antihypertensive drugs such as hydralazine or labetalol are used to treat hypertension in eclampsia.
• Choice B is wrong because corticosteroids do not prevent seizures.Magnesium sulfate is the drug of choice for seizure prophylaxis and treatment in eclampsia.
• Choice D is wrong because corticosteroids do not reduce inflammation in the body.They may have anti-inflammatory effects in some conditions, but their main purpose in eclampsia is to enhance fetal lung development.
Normal ranges for blood pressure and proteinuria in pregnancy are:
• Blood pressure: less than 140/90 mm Hg
• Proteinuria: less than 300 mg/24 hours or less than 1+ on dipstick
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