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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?

A.

Respiratory rate of 16 breaths per minute

B.

Fetal heart rate of 158 beats per minute

C.

Persistent headache for 30 minutes

D.

Urinary output of 40 mL in 2 hours

Answer and Explanation

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 A

Explanation

Choice A rationale

The client’s symptoms of elevated blood pressure, 3+ edema in the lower extremities, and 3+ proteinuria are indicative of preeclampsia. Preeclampsia is a complication of pregnancy that begins after 20 weeks of gestation in women whose blood pressure had previously been in the standard range. It is associated with high blood pressure and signs of damage to another organ system, often the liver and kidneys. In this case, the nurse should initiate seizure precautions and monitor the client’s neurological status and liver function studies. Seizure precautions are necessary because eclampsia, a severe form of preeclampsia, can lead to seizures. Monitoring neurological status can help detect changes in the client’s condition, and liver function studies can help assess the impact of preeclampsia on the liver.

Choice B rationale

While the client does have a history of chronic hypertension, the current symptoms suggest a condition more severe than chronic hypertension. Administering antihypertensive medication and monitoring blood pressure and heart rate would be appropriate actions for managing chronic hypertension, but they may not be sufficient to address the client’s current condition.

Choice C rationale

Gestational diabetes is a condition characterized by high blood sugar levels that develop during pregnancy in women who did not have diabetes before pregnancy. The client’s symptoms do not indicate gestational diabetes. While administering insulin and monitoring blood glucose levels and fetal heart rate would be appropriate actions for managing gestational diabetes, they do not address the client’s current symptoms.

Choice D rationale

Preterm labor refers to regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks of pregnancy. The client’s symptoms do not suggest preterm labor. Administering tocolytics and monitoring contraction pattern and cervical dilation would be appropriate actions for managing preterm labor, but they do not address the client’s current symptoms.

Correct Answer is ["0504."]

Explanation

To calculate the estimated date of birth (EDB) from the last menstrual period (LMP), follow these steps: Determine the first day of the last menstrual period. In this case, it’s July 27. Count back 3 calendar months from that date, which gives us April 27. Lastly, add 1 year and 7 days to that date. This gives us an EDB of May 4, 2024. So, the EDB in MMDD format is 0504.

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