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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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.
Correct Answer is C
Explanation
Choice A rationale
Magnesium sulfate is primarily used for neuroprotection in preterm infants and to prevent seizures in severe preeclampsia, not as a first-line tocolytic for preterm labor.
Choice B rationale
Morphine sulfate is an opioid analgesic used for pain management, not for inhibiting preterm labor contractions.
Choice C rationale
Terbutaline is a beta-agonist used as a tocolytic to relax uterine muscles and delay preterm labor. It helps decrease the intensity and frequency of contractions, making it suitable for managing preterm labor.
Choice D rationale
Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not for direct contraction inhibition.