A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?
Increased respiratory rate
Increased fetal movement
Increased urinary output
Increased muscle weakness
The Correct Answer is D
When caring for a client with preeclampsia receiving magnesium sulfate, the nurse should instruct the client to report any increased muscle weakness. Magnesium sulfate is a medication commonly used to prevent and treat seizures in clients with preeclampsia. However, one of the side effects of magnesium sulfate is muscle weakness. If the client experiences an increase in muscle weakness, it could indicate magnesium toxicity, which requires immediate medical attention.
Option a) Increased respiratory rate is not typically associated with magnesium sulfate administration. However, respiratory depression is a potential side effect, so a decreased respiratory rate should be reported.
Option b) Increased fetal movement is generally considered a positive sign of fetal well-being and is not a concern that needs to be reported.
Option c) Increased urinary output is not typically a concerning finding. In fact, maintaining adequate urine output is desired in clients with preeclampsia to ensure proper kidney function. However, a sudden decrease in urinary output or signs of dehydration should be reported.
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Correct Answer is C
Explanation
Hypoglycemia is a condition in which the blood sugar (glucose) level is too low. Glucose is the main source
of energy for the brain and the body. Newborns need a steady supply of glucose to maintain normal body
functions and growth. Hypoglycemia can occur in newborns for various reasons, such as prematurity, infection, birth asphyxia, maternal diabetes, or inadequate feeding¹.
Hypoglycemia can cause various symptoms in newborns, depending on the severity and duration of the low blood sugar level. Some of the common symptoms include:
- Jitteriness or tremors
- Irritability or crying
- Lethargy or sleepiness
- Poor feeding or sucking
- Low body temperature
- Pale or blue skin color
- Sweating
- Rapid breathing or heart rate
- Seizures or coma
Jitteriness is one of the earliest and most frequent signs of hypoglycemia in newborns². It is caused by the stimulation of the nervous system by low blood sugar levels. Jitteriness can be distinguished from seizures by several features, such as:
- Jitteriness is provoked by stimuli, such as noise or touch, while seizures occur spontaneously
- Jitteriness stops when the stimulus is removed or when the baby is held, while seizures persist
- Jitteriness involves rapid movements of the limbs, chin, or trunk, while seizures involve rhythmic jerking of
the limbs or eyes
- Jitteriness does not affect the level of consciousness, while seizures may cause the baby to be unresponsive
The other options are not typical signs of hypoglycemia in newborns and have different causes:
a) Petechiae are small red or purple spots on the skin caused by bleeding under the skin. They can occur due to trauma during delivery, infection, clotting disorders, or low platelet count.
b) Increased muscle tone is a state of increased tension or stiffness in the muscles. It can occur due to neurological disorders, such as cerebral palsy, spinal cord injury, or brain damage.
d) Abdominal distention is a condition in which the abdomen becomes swollen or enlarged. It can occur due to various causes, such as intestinal obstruction, gas accumulation, organ enlargement, fluid accumulation, or tumor.
Correct Answer is B
Explanation
When providing postpartum care teaching to a client, the nurse should include accurate and appropriate information. Option b) "You can expect your breasts to be firm and tender 3 to 5 days after delivery" is a correct statement.
Breast engorgement is a common occurrence around the third to fifth day after delivery as the breasts transition from producing colostrum to mature milk. This can cause the breasts to become firm, swollen, and tender. It is important for the client to be aware of this normal physiological change and to understand how to manage it effectively, such as by applying warm or cold compresses, expressing milk, and ensuring proper breastfeeding techniques.
Option a) "Your bleeding will remain bright red for the next 6 to 8 weeks" is an incorrect statement. After childbirth, the bleeding, called lochia, typically progresses from bright red to a pinkish color and then to a yellowish-white discharge. The duration and characteristics of lochia can vary for each individual, but it generally resolves within a few weeks.
Option c) "You don't need to use birth control if you are exclusively breastfeeding" is an incorrect statement. While breastfeeding can provide some natural contraception, it is not foolproof, and the client can still ovulate and become pregnant. It is important for the client to discuss and choose a suitable method of contraception with her healthcare provider.
Option d) "You should begin performing Kegel exercises 6 to 7 weeks after delivery" is an incorrect statement. Kegel exercises, which strengthen the pelvic floor muscles, can be started as early as the immediate postpartum period and are beneficial for promoting bladder and bowel control, as well as aiding in postpartum recovery. The client can begin performing Kegel exercises soon after delivery, as guided by her healthcare provider.
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