The nurse is assisting in the care of the client who is at 30 weeks of gestation.
Nurses' Notes
1200:
Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.
Encouraged client to cough and take deep breaths regularly.
Assisted with insertion of 18-gauge IV and initiation of IV fluid.
Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict input/output monitoring; total intake 180 mL/hour.
FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.
1400:
Magnesium sulfate infusion ongoing.
Client is lethargic. Heart rate regular 58bpm, blood pressure 148/99 mmHg, respirations shallow DTR 1+ bilaterally.
Urine output 20 mL in the last hour
1405:
Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.
1800:
Client is alert and responsive. Heart rate regular 78bpm, respirations even and unlabored. DTR 2+ bilaterally
Oxygen saturation (SaO) 95% on 2 L nasal cannula. Respiratory rate 18/min. Blood pressure 146/96 mm Hg.
Select the findings that indicate the client's condition has improved.
Urine output 40 mL in the last hour
Temperature 38.3°C(101 F)
Blood pressure 146/96 mm Hg
Deep tendon reflexes 2+ bilaterally
Heart rate 78/min
Correct Answer : D,E
Deep tendon reflexes (DTR): At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.
Heart rate: At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.
Other findings:
Urine output 40 mL in the last hour: Adequate urine output (at least 30 mL/hr) is a sign of improved renal perfusion and hydration status. Earlier, the client had only 20 mL in the last hour, which was concerning.
Temperature 38.3°C (101°F): This indicates a fever, which is not a sign of improvement.
Blood pressure 146/96 mm Hg: Although this is better than a severely hypertensive reading, it is still elevated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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