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 C
Explanation
Choice A rationale
While congenital anomalies, growth restriction, and fetal distress during labor can occur in pregnancies, they are not directly associated with polyhydramnios. Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid in the uterus during pregnancy.
Choice B rationale
Carrying more than one fetus can lead to a condition known as twin-to-twin transfusion syndrome, which can result in polyhydramnios in one twin and oligohydramnios in the other. However, carrying more than one fetus does not directly mean the mother will experience polyhydramnios.
Choice C rationale
Polyhydramnios is indeed characterized by an excessive amount of amniotic fluid present in the uterus during pregnancy. This can be due to various reasons such as fetal abnormalities, maternal diabetes, and others.
Choice D rationale
An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid can be an indication of certain fetal abnormalities, but it is not a direct indicator of polyhydramnios.
Correct Answer is D
Explanation
Choice A rationale
The largest fetal diameter passing through the pelvic outlet is not what is indicated by the presenting part being at 0 station. This would be more indicative of a positive station, such as
+31.
Choice B rationale
The position of the fetal head, such as left occiput posterior, is not determined by the station of the presenting part. The station refers to the level of the presenting part in relation to the mother’s ischial spines.
Choice C rationale
The palpability of the posterior fontanel is not related to the station of the presenting part. The fontanels are soft spots on the baby’s head which allow for compression during birth and brain growth after birth.
Choice D rationale
This is the correct interpretation of the clinical finding. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines.
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