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
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Chadwick's sign. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva caused by increased blood flow to these areas during pregnancy. It usually appears around 6 to 8 weeks of gestation and persists until delivery. It is one of the presumptive signs of pregnancy, which are subjective changes that suggest pregnancy but are not conclusive. Ballottement is a technique of palpating the uterus to detect fetal movement when a finger is inserted into the vagina and tapped against the cervix. It can be performed between 16 and 28 weeks of gestation and is also a presumptive sign of pregnancy.
Chloasma is a condition characterized by brown patches on the face that may occur during pregnancy due to hormonal changes. It is also known as melasma or mask of pregnancy and usually fades after delivery. Hegar's sign is a softening of the lower uterine segment that can be felt during bimanual examination around 6 weeks of gestation. It is one of the probable signs of pregnancy, which are objective changes that strongly indicate pregnancy but are not diagnostic.
Correct Answer is A
Explanation
Choice A reason:
The statement is correct because chickenpox is highly contagious, and visiting someone with active chickenpox can put the pregnant individual at risk of contracting the infection. The recommendation is to avoid contact with individuals who have chickenpox, especially during pregnancy. The correct approach is to stay away from the infected person until they are no longer contagious (which is usually after all the sores have crusted over and dried up).
Choice B reason:
The statement Is incorrect because taking antibiotics for a viral infection is not appropriate, as antibiotics are only effective against bacterial infections, not viruses. Using antibiotics inappropriately can lead to antibiotic resistance and other potential side effects. Viral infections are generally managed with supportive care.
Choice C reason:
The statement is incorrect because handwashing is an essential infection prevention measure, but washing hands for 10 seconds with hot water may not be sufficient to remove germs effectively. The recommended duration for handwashing is at least 20 seconds with soap and water.
Choice D reason:
The statement is incorrect because cleaning a cat's litter box during pregnancy is not recommended due to the potential risk of exposure to the parasite Toxoplasma gondii, which is found in cat faeces. Toxoplasmosis can cause serious health issues in the developing foetus. It is best for pregnant individuals to avoid cleaning the litter box and have someone else do it or wear gloves and wash hands thoroughly afterward if no one else can do it.
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