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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering oxygen via face mask is a common intervention for various complications during labor. However, it is not the priority action when late decelerations are observed on the fetal monitor. Late decelerations are a sign of fetal hypoxia, which is often caused by uteroplacental insufficiency. While oxygen administration can help increase the overall oxygen available, it does not directly address the cause of the late decelerations.
Choice B rationale
Increasing the rate of the IV fluid infusion can help improve maternal circulation and potentially increase placental perfusion. However, this intervention is not the most immediate or effective response to late decelerations.
Choice C rationale
Elevating the client’s legs is not the recommended action in response to late decelerations. This position does not alleviate the cause of late decelerations and can actually impede blood flow to the uterus.
Choice D rationale
Positioning the client on her side, specifically the left side, is the priority action when late decelerations are observed. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.
Correct Answer is B
Explanation
Choice A rationale
While cigarette smoking can increase the risk of many complications during pregnancy, including placental abruption, it is not the most common risk factor. Smoking can cause constriction and damage to the blood vessels in the placenta, but other factors, such as hypertension, are more commonly associated with placental abruption.
Choice B rationale
Hypertension is the most common risk factor for placental abruption. High blood pressure can cause damage to the blood vessels in the placenta, leading to abruption. Chronic hypertension, gestational hypertension, and preeclampsia can all increase a woman’s risk of experiencing a placental abruption.
Choice C rationale
Blunt force trauma, such as that experienced in a car accident or a fall, can cause placental abruption, but it is not the most common risk factor. Any trauma to the abdomen during pregnancy should be evaluated by a healthcare provider to assess for potential complications, including placental abruption.
Choice D rationale
Cocaine use can increase the risk of placental abruption. Cocaine causes intense vasoconstriction, which can compromise the blood flow to the placenta and lead to abruption. However, it is not the most common risk factor for this condition.
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