A nurse is monitoring a client who is receiving magnesium sulfate to manage preeclampsia.
Which of the following observations should the nurse immediately report to the healthcare provider?
The client’s respiratory rate is 16/min.
The client has had a headache for 30 minutes.
The client’s urinary output is 40 ml in 2 hours.
The client’s fetal heart rate is 158/min.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: A respiratory rate of 16/min is within the normal range for an adult and does not indicate immediate concern.
Choice B rationale: A headache can be a symptom of preeclampsia, but it is not as immediate a concern as the other options unless it is severe or accompanied by other symptoms.
Choice C rationale: A urinary output of 40 ml in 2 hours is significantly below the normal range. Oliguria (low urine output) can be a sign of renal impairment and magnesium toxicity, which requires immediate reporting to the healthcare provider.
Choice D rationale: A fetal heart rate of 158/min is within the normal range for a fetus and does not indicate immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, it’s common for women to have difficulty emptying their bladder. If the bladder becomes too full, it can push the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with a distended bladder. After childbirth, it’s normal for women to experience contractions as the uterus begins to shrink back to its pre-pregnancy size.
Choice C rationale
Increased thirst is not typically a sign of a distended bladder. It’s common for women to feel thirsty as their body adjusts after childbirth.
Choice D rationale
Less than 2.5 cm of rubra lochia on the perineal pad is not typically a sign of a distended bladder. Lochia is the vaginal discharge women experience after childbirth. It’s not related to bladder function.
Correct Answer is A,B,C
Explanation
Choice A rationale
Checking the newborn’s capillary blood glucose level is important, especially for a large for gestational age newborn. Large for gestational age newborns are at risk for hypoglycemia (low blood sugar) after birth. Therefore, regular monitoring of the newborn’s blood glucose level is crucial.
Choice B rationale
Placing the newborn under a radiant warmer can help regulate the baby’s body temperature. Newborns, especially those who are large for gestational age, may have difficulty maintaining their body temperature after birth. A radiant warmer can provide the extra warmth the baby needs.
Choice C rationale
Monitoring the newborn’s temperature is important as newborns can lose heat rapidly, they don’t have the ability to control their body temperature as adults do. Temperature regulation in newborns is important to help them stay healthy and comfortable.
Choice D rationale
Monitoring the newborn’s color and frequency of bowel movements is not directly related to the condition described. While it’s an important aspect of newborn care, it’s not a priority in this scenario.
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