A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin.

Which of the following findings should the nurse report to the provider immediately?

Contractions lasting 90 seconds and occurring every 2 minutes

Fetal heart rate baseline of 140/min with moderate variability

Cervical dilation of 4 cm and effacement of 50%

Epigastric pain and nausea

Answer and Explanation

The Correct Answer is D

Epigastric pain and nausea. This is because epigastric pain and nausea are signs of severe preeclampsia that indicate liver involvement and possible hepatic rupture.

This is a medical emergency that requires immediate intervention to prevent maternal and fetal complications.

Choice A is wrong because contractions lasting 90 seconds and occurring every 2 minutes are normal during labor induction with oxytocin and do not indicate severe preeclampsia.

Choice B is wrong because fetal heart rate baseline of 140/min with moderate variability is a reassuring sign of fetal well-being and does not indicate severe preeclampsia.

Choice C is wrong because cervical dilation of 4 cm and effacement of 50% are normal findings during labor induction and do not indicate severe preeclampsia.

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Correct Answer is C

Explanation

Calcium gluconate is the antidote for magnesium sulfate overdose.Magnesium sulfate blocks calcium, so calcium gluconate can reverse the effect of an overdose.

The other choices are not antidotes for magnesium sulfate.Choice A, naloxone, is the antidote for narcotics or opioid overdose.Choice B, flumazenil, is the antidote for benzodiazepine overdose.Choice D, protamine sulfate, is the antidote for heparin overdose.The normal range of magnesium level is 1.5 to 2.5 mEq/L, so a level of 10 mg/dL indicates toxicity.

A. Hourly intake and output B. Deep tendon reflexes C. Lung sounds D. Level of consciousness

Correct Answer is D

Explanation

Level of consciousness.

This is because magnesium sulfate, which is given to prevent seizures in severe preeclampsia, can cause respiratory depression and coma if the dose is too high.Therefore, the nurse should monitor the client’s level of consciousness and respiratory rate closely and report any signs of toxicity to the provider.

Choice A is wrong because hourly intake and output is not the most important assessment for this client.However, the nurse should monitor the urinary output as a sign of renal function and fluid balance and report any output less than 30 ml per hour.

Choice B is wrong because deep tendon reflexes are not the most important assessment for this client.However, the nurse should check the reflexes as a sign of neuromuscular irritability and report any hyperreflexia or clonus.

Choice C is wrong because lung sounds are not the most important assessment for this client.However, the nurse should auscultate the lungs as a sign of pulmonary edema and report any crackles or wheezes.

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A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin. Which of the following findings should the nurse report to the provider immediately?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with eclampsia who is receiving magnesium sulfate and has a magnesium level of 10 mg/dL. Which of the following medications should the nurse have available as an antidote?

Correct Answer is C

Explanation

A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following assessments is the most important for the nurse to perform?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who had pre-eclampsia and delivered a healthy newborn. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion. What nursing interventions are appropriate for this client? Select all that apply.

A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia. Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who has eclampsia. Which of the following outcomes indicates that the therapy is successful?

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation. The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?

A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following results should the nurse notify the provider about? (Select all that apply.)

A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin.

Which of the following findings should the nurse report to the provider immediately?