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
Prior amniotic fluid leakage is not a required criterion for amniotomy. The main concern is cervical readiness and fetal head position, not previous leakage.
Choice B rationale
The fetal head engaged in the maternal pelvis ensures proper pressure and position for safe amniotomy. Engagement reduces the risk of umbilical cord prolapse and injury.
Choice C rationale
Certification of the nurse for amniotomy is not a standard criterion. The procedure is performed by qualified professionals, but certification isn't a prerequisite for the procedure to be scheduled.
Choice D rationale
Ultrasound to check the umbilical cord's position isn't a standard pre-amniotomy criterion. While it can be useful, the primary concern is the fetal head engagement and cervical readiness.
Correct Answer is A
Explanation
Choice A rationale
PTB is the leading cause of neonatal mortality and for antenatal hospitalization. This is accurate because preterm birth (PTB) is a significant cause of infant mortality and often
requires extended hospital stays for the management of complications.
Choice B rationale
PTBs result in increased numbers of neonatal and infant deaths and long-term neurological impairment. This is accurate because preterm births are associated with higher rates of
mortality and long-term health issues in infants.
Choice C rationale
PTL is defined as regular uterine contractions resulting in cervical changes before 37 weeks gestation. This is accurate because preterm labor (PTL) is indeed characterized by these
symptoms occurring before full-term pregnancy.
Choice D rationale
Average costs for premature/low birthweight infants are more than 10 times as high than for other newborns. This is accurate because medical care for premature and low
birthweight infants is significantly more expensive due to the need for specialized care and extended hospital stays.