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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Respiratory rate of 10 breaths/minute.This indicates that the client is experiencingmagnesium toxicity, which can causemuscle weakness,difficulty breathing, andcardiac arrest.The normal respiratory rate for adults is 12 to 20 breaths/minute.
Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.
Choice C is wrong because urinary output of 40 mL/hour is within the normal range of 30 to 50 mL/hour.Magnesium toxicity can cause urine retention, not increased output.
Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L.Magnesium toxicity occurs when the level is above 2.6 mEq/L.
Correct Answer is C
Explanation
Labetalol is an antihypertensive drug that can lower blood pressure in pregnant women with preeclampsia.Preeclampsia is a condition that causes high blood pressure and proteinuria after 20 weeks of gestation.
Choice A is wrong because hydralazine is not recommended as a first-line treatment for preeclampsia due to its potential adverse effects on maternal and fetal outcomes.
Choice B is wrong because nifedipine is not licensed for use in pregnancy and may interact with magnesium sulfate, which is an anticonvulsant medication used to prevent or treat seizures in severe preeclampsia.
Choice D is wrong because methyldopa is not effective for acute blood pressure control and may cause adverse effects such as depression, sedation, and hemolytic anemia.
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