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 C
Explanation
Choice A rationale
A 15-year-old, G3 P0020, although young, doesn't have an increased risk of uterine rupture related to prior surgical deliveries or other known factors.
Choice B rationale
A 22-year-old, G1 P0000 with eclampsia requires close monitoring for complications related to eclampsia but not specifically for uterine rupture.
Choice C rationale
A 25-year-old, G4 P3003 with a previous cesarean section is at increased risk for uterine rupture due to the scar from the prior surgery which could weaken under the stress of labor.
Choice D rationale
A 32-year-old, G2 P0100's history of a prior fetal demise does not specifically increase the risk of uterine rupture unless accompanied by other risk factors. .
Correct Answer is B
Explanation
Choice A rationale
Decreased muscle tone is not typically associated with neonatal abstinence syndrome (NAS). Instead, NAS often presents with hypertonia or increased muscle tone due to
withdrawal symptoms.
Choice B rationale
A continuous high-pitched cry is a hallmark sign of NAS, indicating the newborn is experiencing withdrawal and discomfort. This symptom results from the overstimulation of the
central nervous system.
Choice C rationale
Newborns with NAS often have difficulty sleeping and may sleep for shorter periods due to irritability and discomfort. Prolonged sleep after feeding is not characteristic of NAS.
Choice D rationale
Tremors in newborns with NAS are usually pronounced and continuous, not just when disturbed. These tremors are a result of withdrawal effects on the nervous system.