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 A
Explanation
Choice A rationale
Methylergonovine is a medication that is primarily used to prevent or treat excessive bleeding after childbirth. It works by increasing the rate and strength of contractions and the stiffness of the uterus muscles, which helps to decrease bleeding. This medication is given in a hospital or clinic setting. Therefore, the nurse should inform the client that this medication is intended to prevent postpartum hemorrhage.
Choice B rationale
While preventing postpartum infection is important, methylergonovine is not specifically used for this purpose. Postpartum infection is typically prevented and treated with antibiotics and good hygiene practices.
Choice C rationale
Thromboembolic events, such as blood clots, can be a risk after childbirth. However, methylergonovine is not used to prevent these events. Anticoagulant medications are typically used to prevent thromboembolic events.
Choice D rationale
Methylergonovine is not used to prevent hypertension. In fact, it can cause increased blood pressure as a side effect. Therefore, it would not be used as a preventative measure for hypertension.
Correct Answer is A
Explanation
Choice A rationale
This is the best response because it acknowledges the client’s question and refers her to a healthcare provider who can provide a comprehensive assessment and discuss the most appropriate contraceptive options for her specific situation.
Choice B rationale
While it’s important to understand a client’s sexual activity when discussing contraception, asking a minor about her sexual activity without a proper context or professional setting may be inappropriate and uncomfortable for the client.
Choice C rationale
This response may come off as judgmental or condescending. It’s crucial to provide a safe and non-judgmental environment when discussing sensitive topics like sexual health and contraception.
Choice D rationale
While barrier methods can be an effective form of contraception, it’s not appropriate to recommend a specific method without a thorough understanding of the client’s health history, lifestyle, and preferences.
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