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?
Patellar and biceps reflexes of 3+.
Urinary output of 30 mL/hr.
Respiratory rate of 16 rpm.
Serum magnesium level of 10 mg/dL. .
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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Correct Answer is A
Explanation
Choice A rationale
A 37-year-old patient with obesity and pregnancy-induced hypertension presents multiple risk factors. Advanced maternal age, obesity, and hypertension collectively increase the
likelihood of complications such as preeclampsia, gestational diabetes, and cesarean delivery, necessitating close monitoring and management.
Choice B rationale
A patient with preexisting hypertension and twins is indeed high-risk due to the combined strain on the cardiovascular system and potential for preterm labor or other complications
associated with multiple gestations. However, the presence of pregnancy-induced hypertension and obesity in the first patient poses a slightly higher cumulative risk.
Choice C rationale
A 16-year-old patient with newly diagnosed gestational diabetes is at increased risk, particularly because of age and the potential for poorly managed diabetes leading to
complications. However, this scenario presents fewer immediate cumulative risks compared to older age and existing hypertension.
Choice D rationale
A 28-year-old patient who had a premature birth three years prior must be monitored for signs of recurrent preterm labor. Yet, this history alone does not present as high a cumulative
risk as older maternal age, obesity, and pregnancy-induced hypertension. .
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Massaging the fundus helps to stimulate uterine contractions, reducing bleeding and promoting firmness in the uterus. Ensuring IV access is critical for administering medications and
fluids quickly.
Choice B rationale
Methylergonovine (Methergine) is used to prevent and control postpartum hemorrhage by promoting uterine contractions. Oxytocin bolus also helps stimulate contractions, preventing
further blood loss.
Choice C rationale
Carboprost tromethamine (Hemabate) is another uterotonic agent used to control severe postpartum hemorrhage by causing uterine contractions. Its use depends on the patient's
response to other treatments.