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
Hypotension, or low blood pressure, is a common complication from an epidural block16. This occurs because the medication used in the epidural can block sympathetic nerve fibers, which can cause blood vessels to dilate and lead to a drop in blood pressure16.
Choice B rationale
Vomiting is not typically a direct complication of an epidural block16. Nausea and vomiting during labor can have many causes, including the physical process of labor, pain, and medications.
Choice C rationale
Tachycardia, or a fast heart rate, is not typically a complication of an epidural block16. In fact, some of the medications used in an epidural can actually cause a slower heart rate.
Choice D rationale
While severe respiratory depression can occur with an epidural, it is extremely rare16. More commonly, an epidural can cause a feeling of breathlessness or difficulty taking a deep breath, but it should not cause significant respiratory depression.
Correct Answer is B
Explanation
Choice A rationale
While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.
Choice B rationale
A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.
Choice C rationale
Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.
Choice D rationale
Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.
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