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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Neonatal abstinence syndrome is a condition that results from withdrawal from exposure to narcotics. It is not related to the newborn’s weight.
Choice B rationale
While a yellowish skin tone may indicate jaundice, this is not directly related to the newborn’s weight. Jaundice is caused by an excess of bilirubin, a yellow-orange substance in the blood.
Choice C rationale
Newborns with low birth weight are at risk for hypoglycemia because they have less stored glycogen. They may use up their glucose stores quickly and not have enough intake to maintain their blood glucose levels.
Choice D rationale
Neonatal sepsis is a severe infection in an infant less than 28 days old. It is not directly related to the newborn’s weight but can be associated with maternal infection.
Correct Answer is A
Explanation
Choice A rationale
The recommended time for rubella immunization for a woman who does not have immunity is shortly after giving birth. The MMR vaccine, which protects against measles, mumps, and rubella, is a live virus vaccine and is not recommended during pregnancy.
Choice B rationale
While it’s important for a woman to have immunity to rubella before her next pregnancy, waiting until her next attempt to get pregnant to get the vaccine could potentially leave her unprotected if she becomes pregnant sooner than planned.
Choice C rationale
The MMR vaccine is not recommended during pregnancy, including in the third trimester.
Choice D rationale
The MMR vaccine is not recommended during pregnancy, including in the second trimester.
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