A nurse is caring for a client who is at 35 weeks of gestation and is receiving magnesium sulfate for treatment of preeclampsia.
Which of the following findings indicates that the medication is having the desired effect?
Urinary output of 20 mL/hr.
Fetal heart rate pattern with minimal variability.
Fetal heart rate changed from 150/min to 166/min.
Deep tendon reflexes changed from 4+ to 2+.
The Correct Answer is D
Choice A rationale
Urinary output of 20 mL/hr is indicative of oliguria, which is a significant adverse effect of magnesium sulfate therapy. Magnesium is renally excreted, and decreased urinary output can lead to magnesium toxicity. The desired urinary output for a client receiving magnesium sulfate should be at least 25 to 30 mL/hr to ensure adequate drug excretion.
Choice B rationale
Fetal heart rate pattern with minimal variability is a concerning finding and can indicate central nervous system depression in the fetus, potentially due to excessive magnesium levels. Normal fetal heart rate variability reflects a healthy autonomic nervous system. Magnesium sulfate's therapeutic effect is on the mother, not directly on fetal heart rate variability.
Choice C rationale
A change in fetal heart rate from 150/min to 166/min, while still within the normal range (110-160 bpm), does not directly indicate the desired therapeutic effect of magnesium sulfate for preeclampsia. This fluctuation could be due to various factors and is not a primary indicator of successful seizure prophylaxis or blood pressure control.
Choice D rationale
Magnesium sulfate is a central nervous system depressant that works by blocking neuromuscular transmission, thereby reducing hyperreflexia associated with preeclampsia. A decrease in deep tendon reflexes from 4+ (hyperactive) to 2+ (normal) indicates that the medication is achieving its desired therapeutic effect of central nervous system depression and reducing seizure risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Immediately bathing a newborn with herpes simplex virus is generally discouraged. While it might seem intuitive for infection control, vigorous bathing could theoretically disrupt skin integrity and potentially spread the virus to other areas of the body or mucous membranes, exacerbating the infection.
Choice B rationale
Initiating contact precautions is essential for a newborn with herpes simplex virus. This highly contagious viral infection requires strict measures to prevent transmission to other vulnerable neonates and healthcare providers. Contact precautions involve gown and glove use, limiting direct contact with the newborn or contaminated surfaces.
Choice C rationale
Administering ampicillin IV is not the appropriate treatment for herpes simplex virus. Ampicillin is an antibiotic effective against bacterial infections, not viral infections like herpes simplex. Antiviral medications, such as acyclovir, are the specific treatment for neonatal herpes simplex virus to inhibit viral replication.
Choice D rationale
Withholding breastfeeding is not typically indicated for a newborn with in utero transmitted herpes simplex virus unless the mother has active lesions on her breasts. The primary concern is direct skin-to-skin transmission if lesions are present. Breast milk itself provides beneficial antibodies and is not a route of transmission for in utero infection.
Correct Answer is D
Explanation
A. The bladder is distended upon palpation: A distended bladder suggests urinary retention, not effective voiding. This may impair uterine contraction and increase the risk of hemorrhage.
B. The uterine fundus is 2 cm above the umbilicus: A high-rising fundus may indicate a full bladder that is displacing the uterus, often due to incomplete voiding.
C. The client does not feel the urge to urinate: Lack of urge may indicate altered bladder sensation, a potential complication after catheter removal and childbirth.
D. The client urinates 30 mL/hr: Urine output of ≥30 mL/hr is considered adequate and reflects effective voiding and kidney function, especially in the postpartum period.
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