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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 C

Explanation

Choice A rationale

While it’s true that increased discomfort is expected with twins due to additional physical strain and space constraints, this alone is not sufficient reassurance. It is vital to assess for

signs of preterm labor or other complications.

Choice B rationale

Performing a digital cervical examination is a valid approach to checking for dilation, but this action must be carefully considered based on other signs and symptoms presented by

the patient. The focus here is on ensuring the absence or presence of labor, which might require hospital assessment.

Choice C rationale

Sending the patient to the hospital to be checked for possible signs of labor ensures that professional monitoring and interventions can occur if labor is confirmed. This action

prioritizes safety, given the increased risk of complications with twin pregnancies and the advanced gestation of 37 weeks.

Choice D rationale

Assuring the patient of the absence of contractions after an examination might provide temporary relief, but it does not address the possibility of other signs of labor or complications

that may require more comprehensive hospital assessment.

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.

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