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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

Contraction duration less than 40 seconds doesn't define tachysystole. Tachysystole focuses on excessive frequency of contractions rather than their duration.

Choice B rationale

Contraction frequency of more than 5 in 10 minutes defines tachysystole. This condition indicates too frequent uterine activity, which can compromise fetal oxygenation.

Choice C rationale

Contraction intensity less than 80 mm Hg doesn't define tachysystole. Tachysystole is characterized by the number of contractions, not their intensity.

Choice D rationale

Resting tone less than 18 mm Hg is not related to the definition of tachysystole. Tachysystole concerns contraction frequency, not the resting tone of the uterus between contractions. .

Correct Answer is A

Explanation

Choice A rationale

Postpartum psychosis poses significant risks to both the mother and her infant. The mother may have impaired judgment, hallucinations, or delusions, making it unsafe for her to be

left alone with her baby.

Choice B rationale

Symptoms of postpartum psychosis can persist for several weeks to months without appropriate treatment. Immediate and ongoing intervention is crucial to manage the condition.

Choice C rationale

Clinical response to medications for postpartum psychosis can vary, but with proper treatment, many clients show significant improvement. It is not accurate to state that the

response is usually poor.

Choice D rationale

While monitoring vitals may be part of overall care, it is not the most critical teaching point. Ensuring the mother is never left alone with her infant is essential to prevent potential

harm.

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