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 B
Explanation
Choice A rationale
Retained tissue can cause postpartum hemorrhage, but with a firm uterus and no other signs of retained placenta, this is less likely the cause here.
Choice B rationale
Trauma is the most likely cause of increased bleeding in this scenario. The prolonged oxytocin induction and macrosomic infant suggest a higher risk of lacerations or uterine atony
despite the firm uterus.
Choice C rationale
Thrombin disorders cause bleeding due to clotting issues. However, this patient shows signs of active bleeding and clotting, making this less likely.
Choice D rationale
Uterine atony, indicated by a soft, boggy uterus, is a common cause of postpartum hemorrhage, but in this case, the uterus is firm, so it's less likely to be the cause.
Correct Answer is D
Explanation
Choice A rationale
Oxytocin is used to induce or augment labor, not typically used before an external version, which is a procedure to turn a breech baby to a head-down position.
Choice B rationale
Methylergonovine is used to prevent or control postpartum hemorrhage by inducing strong uterine contractions, not indicated before an external version.
Choice C rationale
Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not required for an external version.
Choice D rationale
Terbutaline is a tocolytic agent used to relax the uterus, making it easier to manipulate the fetus during the external version procedure.