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
Explanation: Yellow patches in the mouth are an indication of oral candidiasis, also known as thrush, which is a fungal infection caused by Candida albicans. Oral candidiasis can cause symptoms such as pain, burning, redness, and difficulty swallowing in addition to yellow patches on the tongue, palate, cheeks, or throat. Hearing loss, night sweats, and
brittle nails are not manifestations of candida infection.
Correct Answer is D
Explanation
The correct answer is D.
Flex his hips while pulling the client. The nurse and AP should use proper body mechanics when repositioning a client to prevent injury and promote comfort. Flexing the hips while pulling the client reduces strain on the back muscles and allows for greater leverage.
The nurse and AP should raise the bed to a comfortable working height, not lower it to the lowest position. The nurse and AP should stand on opposite sides of the bed near the client's hips, not shoulders. The nurse and AP should remove any pillows under or around the client before repositioning him.
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