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A client is on magnesium sulfate for pre-eclampsia with severe features.
The nurse must notify the attending physician regarding which of the following findings?

A.

Patellar and biceps reflexes of 3+.

B.

Urinary output of 30 mL/hr.

C.

Respiratory rate of 16 rpm.

D.

Serum magnesium level of 10 mg/dL. .

Answer and Explanation

The Correct Answer is D

Choice A rationale

Reflexes of 3+ indicate hyperreflexia, common in pre-eclampsia, but not necessarily critical. Monitoring is essential but not an emergency.

 

Choice B rationale

Urinary output of 30 mL/hr is within the acceptable range but requires monitoring for any changes. It's not a critical alert.

 

Choice C rationale

A respiratory rate of 16 rpm is normal and does not indicate immediate risk requiring physician notification.

 

Choice D rationale

Serum magnesium level of 10 mg/dL is significantly high, indicating potential toxicity. Immediate physician notification is critical to adjust magnesium sulfate administration.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

While infection prevention is vital, ensuring breathing function is more critical after ASP.

Choice B rationale

ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.

Choice C rationale

Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.

Choice D rationale

Voiding without pain is important, but respiratory stability takes precedence.

Correct Answer is B

Explanation

Choice A rationale

Oral rehydration therapy is not used in place of feedings for infants undergoing phototherapy for elevated bilirubin levels. It's crucial to maintain proper nutrition and hydration through regular feedings.

Choice B rationale

Rotating the baby helps ensure even exposure to the bili lights, which aids in breaking down bilirubin effectively across the baby's body.

Choice C rationale

Applying restraints is inappropriate and unnecessary. It could cause distress and is not a standard practice for phototherapy.

Choice D rationale

Administering intravenous fluids is not typically needed unless there's a risk of dehydration or other medical indications as per the doctor's orders.

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