A nurse is evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate.

Which of the following findings should the nurse report to the provider as a sign of fetal compromise?

Fetal heart rate of 140 beats/min

Fetal movement of 10 times in an hour

Oligohydramnios on ultrasound

Reactive nonstress test

Answer and Explanation

The Correct Answer is C

Oligohydramnios on ultrasound. Oligohydramnios is a condition where the amniotic fluid volume is less than expected for gestational age. It can be a sign of fetal compromise due to various causes, such as renal abnormalities, placental insufficiency, premature rupture of membranes, or chromosomal anomalies. Oligohydramnios can lead to complications such as fetal deformities, preterm birth, infection, or stillbirth.

Choice A is wrong because a fetal heart rate of 140 beats/min is within the normal range for most of pregnancy.

Choice B is wrong because fetal movement of 10 times in an hour is also within the normal range and indicates fetal well-being.

Choice D is wrong because a reactive nonstress test is a reassuring sign that the fetus is not hypoxic or stressed.

Normal ranges:

• Amniotic fluid index (AFI): 5-25 cm

• Fetal heart rate: 110-160 beats/min

• Fetal movement: at least 10 movements in 2 hours

• Nonstress test: at least two accelerations of fetal heart rate of 15 beats/min for 15 seconds or more in 20 minutes

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Correct Answer is C

Explanation

Headache unrelieved by analgesics.This is because headache is a common symptom of HELLP syndrome, a rare pregnancy complication that can cause high blood pressure, seizures, stroke or liver rupture.HELLP syndrome is a type of preeclampsia and has similar symptoms.

Choice A is wrong because breast engorgement is a normal postpartum condition that occurs when the breasts are full of milk and become swollen and tender.

It is not related to HELLP syndrome.

Choice B is wrong because lochia rubra for 3 days postpartum is a normal finding that indicates the shedding of the uterine lining after delivery.

It is not related to HELLP syndrome.

Choice D is wrong because perineal discomfort is a common postpartum discomfort that results from the stretching and tearing of the perineal tissues during vaginal delivery.

It is not related to HELLP syndrome.

Normal ranges for blood pressure are less than 120/80 mmHg, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT.

A. The client has no seizures B. The client has a diuresis C. The client has improved fetal movement D. The client has increased platelet count

Correct Answer is A

Explanation

The client has no seizures.Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia and eclampsia.Seizures are a life-threatening complication of eclampsia and indicate a failure of therapy.

Choice B is wrong because diuresis is not a goal of magnesium sulfate therapy.Diuresis may indicate fluid overload or renal impairment, which are complications of preeclampsia and eclampsia.

Choice C is wrong because improved fetal movement is not a direct outcome of magnesium sulfate therapy.Fetal movement may be affected by many factors, such as gestational age, maternal position, and fetal well-being.

Choice D is wrong because increased platelet count is not a result of magnesium sulfate therapy.Platelet count may be decreased in preeclampsia and eclampsia due to disseminated intravascular coagulation, which is a serious complication that requires prompt treatment.

Normal ranges for blood pressure are less than 140/90 mm Hg, for proteinuria are less than 300 mg/24 hours, for platelet count are 150,000 to 400,000/mm3, and for serum magnesium are 1.5 to 2.5 mEq/L.

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A nurse is evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider as a sign of fetal compromise?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate.

Which of the following findings should the nurse report to the provider as a sign of fetal compromise?