A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia.
Which of the following observations should the nurse report to the healthcare provider?
Respiratory rate of 16 breaths per minute
Fetal heart rate of 158 beats per minute
Persistent headache for 30 minutes
Urinary output of 40 mL in 2 hours
The Correct Answer is D
Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
-
G (Gravida): Total number of pregnancies → 4
-
T (Term births): Delivered at 37 weeks or more → One (39 weeks) → T = 1
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P (Preterm births): Delivered between 20–36 weeks → Twins (34 weeks, 1 pregnancy) + One at 35 weeks = 2 preterm pregnancies → P = 2
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A (Abortions): Pregnancies ending before 20 weeks → 0
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L (Living children): One from term birth, two from twins, and one from the other preterm = 4 living children → L = 4
Correct Answer: D. G4 T1 P2 A0 L4
Correct Answer is ["-"]
Explanation
The nurse is observing a potential case of shoulder dystocia, a condition where the baby’s head has been delivered but one of the shoulders becomes stuck behind the mother’s pelvic bone. The nurse should monitor the mother’s vital signs and the baby’s heart rate. The nurse should call for immediate assistance, perform maneuvers to help deliver the baby, and prepare for a potential emergency cesarean section if necessary.
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