A nurse receives a shift report and must first assess the high-risk antenatal client who is:
35 weeks gestation with proteinuria and vomiting.
39 weeks gestation with urinary urgency, frequency, and burning.
30 weeks gestation with a fasting blood sugar of 95 mg/dL and a 3-hour glucose of 120.
34 weeks gestation with a hemoglobin of 12 mg/dL and a potassium level of 3.5 mEq/L. .
The Correct Answer is A
Choice A rationale
Proteinuria and vomiting at 35 weeks gestation are significant symptoms that could indicate preeclampsia, a serious condition that requires immediate assessment and management to prevent complications for both the mother and the baby.
Choice B rationale
Urinary urgency, frequency, and burning at 39 weeks gestation suggest a possible urinary tract infection (UTI), which is concerning but generally not as immediately critical as symptoms suggesting preeclampsia.
Choice C rationale
A fasting blood sugar of 95 mg/dL and a 3-hour glucose of 120 at 30 weeks gestation indicate good control of blood sugar levels, which is not as high-risk as preeclampsia symptoms.
Choice D rationale
A hemoglobin of 12 mg/dL and a potassium level of 3.5 mEq/L at 34 weeks gestation are within normal ranges and do not indicate an immediate high-risk condition compared to the potential for preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","F","G"]
Explanation
Choice A rationale
Respiratory rate of 8 breaths per minute indicates respiratory depression, a serious adverse effect of magnesium sulfate toxicity. Magnesium sulfate can depress neuromuscular transmission, leading to decreased respiratory effort and rate.
Choice B rationale
Blood pressure of 150/90 mmHg is not indicative of magnesium sulfate toxicity. Elevated blood pressure is a symptom of pre-eclampsia and not directly related to the adverse effects of magnesium sulfate. Therefore, it does not indicate toxicity.
Choice C rationale
Lung crackles are typically associated with fluid overload or heart failure rather than magnesium sulfate toxicity. While it is a serious condition, it is not specifically an adverse effect of magnesium sulfate.
Choice D rationale
Increase in fetal heart rate is not a common adverse effect of magnesium sulfate. Fetal heart rate changes are more commonly related to the underlying maternal condition or other medications used in pregnancy rather than magnesium sulfate.
Choice E rationale
Deep tendon reflexes would typically be decreased or absent in magnesium sulfate toxicity. Therefore, presence of deep tendon reflexes would not indicate an adverse effect of magnesium sulfate.
Choice F rationale
Confusion can occur due to central nervous system depression caused by high levels of magnesium sulfate. This is a significant adverse effect indicating possible toxicity.
Choice G rationale
Urine output of 30 mL in 2 hours suggests oliguria, which can be a sign of magnesium sulfate toxicity as the drug is excreted through the kidneys. Reduced urine output can indicate the kidneys are not clearing the drug efficiently, leading to toxicity.
Correct Answer is A
Explanation
Choice A rationale
Reassuring the patient that she will deliver vaginally is inappropriate and could be misleading, especially if there are complications such as placental abruption or severe pre-eclampsia, which may necessitate a cesarean delivery for the safety of the mother and baby.
Choice B rationale
Inserting an indwelling Foley catheter is a standard procedure to monitor urine output and kidney function, especially in cases of pre-eclampsia, where accurate monitoring of fluid balance is crucial.
Choice C rationale
Initiating IV therapy with Lactated Ringer's solution is important to maintain maternal hydration and electrolyte balance, especially if the client is experiencing blood loss and is at risk of hypovolemia.
Choice D rationale
Monitoring the fetal heart tracing is essential to assess the baby's well-being. Continuous fetal monitoring helps detect signs of fetal distress, allowing for timely interventions to ensure the safety of both mother and baby.
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