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
Applying ice packs can help reduce pain and swelling, but it is not the best intervention for a breastfeeding mother with mastitis. Ice can constrict blood vessels and may hinder milk
flow, which can exacerbate the condition.
Choice B rationale
Frequent breastfeeding helps to empty the affected breast and prevent milk stasis, reducing the risk of abscess formation and promoting faster healing. The mechanical action of
nursing can help clear the infection and provide relief.
Choice C rationale
Weaning immediately is not advised as it can lead to engorgement and milk stasis, worsening the infection. Continuing to breastfeed ensures the breast is regularly emptied, aiding
in recovery.
Choice D rationale
While notifying the pediatrician may be necessary if the baby is affected, it does not directly address the mother's condition or provide immediate relief. Primary management focuses
on treating the infection and maintaining milk flow.
Correct Answer is D
Explanation
Choice A rationale
Reduction of fever is not a primary effect of carboprost tromethamine. This medication is primarily used to induce uterine contractions to manage postpartum hemorrhage.
Choice B rationale
While maintaining stable blood pressure is important, it is not the specific indicator of carboprost tromethamine's effectiveness. This medication is used to control bleeding.
Choice C rationale
Increased comfort, although significant, is not the direct effect of carboprost tromethamine. The primary aim is to induce uterine contractions to manage hemorrhage.
Choice D rationale
Decreased lochia rubra indicates the reduction of postpartum bleeding, which is the primary purpose of administering carboprost tromethamine. This outcome shows the medication is effective.