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 A

Explanation

Hydralazine can causetachycardia(fast heart rate) as a common side effect.

This is because hydralazine lowers blood pressure by relaxing blood vessels, which can make the heart beat faster to compensate.

Choice B is wrong because hydralazine does not causehyperglycemia(high blood sugar).

Hydralazine is not known to affect glucose metabolism or insulin secretion.

Choice C is wrong because hydralazine does not causehypokalemia(low potassium levels).

Hydralazine is not a diuretic and does not increase potassium excretion.

Choice D is wrong because hydralazine does not causeconstipation.Hydralazine can causediarrheaas a common side effect, but not constipation.

A. The client has no seizures or eclampsia B. The client delivers a healthy baby vaginally C. The client has normal blood pressure and urine output D. The client has improved liver function and platelet count

Correct Answer is A

Explanation

The client has no seizures or eclampsia.This outcome would indicate that the magnesium sulfate therapy is successful because magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.

Some additional information for the other choices are:

• Choice B. The client delivers a healthy baby vaginally.

This outcome is desirable but not directly related to the effectiveness of magnesium sulfate therapy.Magnesium sulfate can help prolong a pregnancy for up to two days to allow drugs that speed up the baby’s lung development to be administered, but it does not guarantee a vaginal delivery or a healthy baby.

• Choice C. The client has normal blood pressure and urine output.

This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.

Magnesium sulfate may help reduce blood pressure in some cases, but it is not the primary treatment for hypertension in preeclampsia.Other medications such as antihypertensives are usually prescribed for that purpose.Urine output should be monitored closely while receiving magnesium sulfate therapy, as a decrease may indicate toxicity or kidney impairment.Urine output should be at least 30 mL/hour while administering magnesium sulfate.

• Choice D. The client has improved liver function and platelet count.

This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.

Magnesium sulfate does not affect liver function or platelet count in preeclampsia.These parameters may improve after delivery of the placenta, which is the main cause of preeclampsia.

Normal ranges for blood pressure, urine output, liver function and platelet count are:

• Blood pressure: less than 140/90 mm Hg

• Urine output: at least 30 mL/hour

• Liver function: AST and ALT less than 40 U/L, LDH less than 600 U/L, bilirubin less than 1.2 mg/dL

• Platelet count: 150,000 to 450,000 per microliter of blood

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV. Which of the following adverse effects should the nurse monitor for?

Correct Answer is A

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?