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 ["C","E"]
Explanation
The correct answer is choice C and E.A platelet count of 100,000/mm3 is low and indicates a risk of bleeding due to preeclampsia.A urine output of 20 mL/hour is also low and suggests kidney impairment due to magnesium sulfate therapy.
Both of these results should be reported to the provider as they may require intervention.
Choice A is wrong because a serum creatinine of 1.2 mg/dL is within the normal range of 0.6 to 1.3 mg/dL for womenand does not indicate kidney dysfunction.
Choice B is wrong because liver enzymes of 40 U/L are within the normal range of 7 to 55 U/L for women and do not indicate liver damage.
Choice D is wrong because a coagulation profile of 12 seconds is within the normal range of 11 to 13.5 seconds for women and does not indicate a clotting disorder.
Correct Answer is C
Explanation
Calcium gluconate is the antidote for magnesium sulfate overdose.Magnesium sulfate blocks calcium, so calcium gluconate can reverse the effect of an overdose.
The other choices are not antidotes for magnesium sulfate.Choice A, naloxone, is the antidote for narcotics or opioid overdose.Choice B, flumazenil, is the antidote for benzodiazepine overdose.Choice D, protamine sulfate, is the antidote for heparin overdose.The normal range of magnesium level is 1.5 to 2.5 mEq/L, so a level of 10 mg/dL indicates toxicity.
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