OB Midterm Flashcards
A patient is in active labor and is being continuously monitored with a fetal monitor. The patient’s labor has been normal to this point. The patient’s membranes ruptured 1 hour ago, and the fluid was clear. The FHR baseline is 125 bpm. Contractions are occurring every 3 minutes and lasting 60 seconds, and are of moderate intensity with a soft resting tone. On entering the room, the nurse sees the patient lying supine and notices that there has been abrupt slowing in the FHR to 90 bpm during the last two contractions, each episode lasting 30 seconds or less. The patient complains of breathlessness and becomes pale and diaphoretic. What is the most appropriate nursing response?
A. Initiate oxygen therapy at 8 to 10 L/min by face mask and increase nonadditive IV fluid.
B. Reposition the patient, check blood pressure, and continue to monitor the FHR pattern.
C. Notify the practitioner and document findings in the patient’s record.
D. Notify the practitioner and prepare for cesarean delivery
B. Reposition the patient, check blood pressure, and continue to monitor the FHR pattern.
Which of the following is the priority intervention for a supine patient whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends?
A. Increase IV infusion.
B. Elevate lower extremities.
C. Reposition to left side-lying position.
D. Administer oxygen per face mask at 4 to 6 L/minute.
C. Reposition to left side-lying position
Rationale: Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the patient is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the patient is in a supine position.
What do you do if a pregnant patient is laying supine and can’t turn to her side?
Place a wedge under one of the clients hips to tilt the uterus.
Adequate intake of which of the following nutrients has been shown to reduce the risk of neural tube defects?
A) folic acid
B) mercury
C) vitamin D
D) vitamin C
A. Folic Acid
A pregnant patient arrives for her first prenatal visit at the clinic. She informs the nurse that she has been taking an additional 400 mcg of folic acid prior to becoming pregnant. Based on the patient’s history, she has reached 8 weeks’ gestation. Which recommendation would the nurse provide regarding folic acid supplementation?
A. Have the patient continue to take 400 mcg folic acid throughout her pregnancy.
B. Tell the patient that she no longer has to take additional folic acid because it will be included in her prenatal vitamins
C. Have the patient increase her folic acid intake to 1000 mcg throughout the rest of her pregnancy.
D. Schedule the patient to go for an AFP (alpha-fetoprotein) test.
B. Tell the patient that she no longer has to take additional folic acid because it will be included in her prenatal vitamins
The pregnant teen who was prescribed prenatal vitamins at her initial prenatal visit states that she does not like to take them. How should the nurse respond? SATA
A. “Folic acid has been found to be essential for minimizing the risk of neural tube defects.”
B. “You do not have to take these supplements if you think you are healthy enough.”
C. “These medications do the same thing. I will call your doctor to cancel one of your medications.”
D. “You can trust your doctor to know what you need.”
E. You need the supplements because your dietary intake may not be adequate for fetal
development.”
A. Folic acid has been found to be essential..
E. You need the supplements because….
The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient’s contractions. How will the nurse document these findings?
A. Late decelerations
B. Early decelerations
C. Variable decelerations
D. Proximal decelerations
A. Late decelerations
Rationale: Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contraction’s peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal deceleration is not a recognized term.
What are the causes and complications of late decelerations of FHR?
Uteroplacental insufficiency causing inadequate fetal oxygenation
- Maternal hypotension, placenta previa, abruptio placentae, uterine tachysystole with oxytocin
- Preeclampsia
- Late- or post-term pregnancy
- Maternal diabetes mellitus
What is the best nursing action to implement when late decelerations occur?
a. Reposition the patient to supine
b. Decrease flow of intravenous (IV) fluids
c. Increase oxygen to 10 L/minute
d. Prepare to increase oxytocin drip
c. Increase oxygen to 10 L/minute
Rationale: The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension
The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation?
A. This pattern reflects variable decelerations. No interventions are necessary at this time.
B. Document this Category I fetal heart rate pattern and decrease the rate of the intravenous (IV) fluid.
C. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction.
D. This deceleration pattern is associated with uteroplacental insufficiency. The nurse
must act quickly to improve placental blood flow and fetal oxygen supply.
D. This deceleration pattern is associated with uteroplacental insufficiency. The nurse
must act quickly to improve placental blood flow and fetal oxygen supply.
Rationale: A pattern similar to early decelerations, but the deceleration begins near the acme of the
contraction and continues well beyond the end of the contraction, describes a late deceleration. Oxygen should be given via a snug face mask. Position the patient on her left side to increase placental blood flow. Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. This is not a normal pattern, rather it is a Category III tracing, predictive of abnormal fetal acid status at the time of observation. The IV rate should be increased in order to add to the mother’s blood volume. These are late decelerations, not early; therefore interventions are necessary.
What are late decelerations associated with?
Placental insufficiency which can cause -> Hypoxia and Uterine Rupture -> fetal distress
Nursing interventions for fetal late decelerations:
place pt in a side-lying position
-insert an IV catheter and increase the rate of IV infusion -Discontinue oxytocin is being infused
- Administer O2 by mask 8-10 L/min via nonrebreather
- elevate pt legs
- notify hcp
Which data found on a patient’s health history would place her at risk for an ectopic pregnancy?
A. Ovarian cyst 2 years ago
B. Recurrent pelvic infections
C. Use of oral contraceptives for 5 years
D. Heavy menstrual flow of 4 days’ duration
B. Recurrent pelvic infections
Rationale: Infection and subsequent scarring of the fallopian tubes prevent normal movement of the fertilized ovum into the uterus for implantation. Ovarian cysts do not cause scarring of the fallopian tubes. Oral contraceptives do not increase the risk for ectopic pregnancies. Heavy menstrual flow of 4 days’ duration will not cause scarring of the fallopian tubes, which is the main risk factor for ectopic pregnancies.
Signs and Symptoms of Ectopic Pregnancy
-unilateral stabbing pain and tenderness in the lower abdominal quadrant
- Menses that is delayed 1-2 weeks, lighter than usual, or irregular
- SCANT, DARK RED, OR BROWN vaginal spotting 6-8 weeks after last normal menses; red vaginal bleeding if rupture has occurred
-Referred shoulder pain due to blood in the peritoneal cavity
- findings of hemorrhage and shock (hypotension, tachycardia, pallor, dizziness)
A nurse at a provider’s office is caring for a client who is 28 years of age. After reviewing the client’s current assessment findings, the nurse should identify that the client i experiencing ______________(condition) as evidence by ____________(findings)
Condition:
-abruptio placentae
- acute asthma attack
-pyelonephritis
-ectopic pregnancy
-placenta previa
Findings:
-a history of regular menstrual period
- right lower quadrant abdominal tenderness
-hyperactive bowel sounds
-temperature
-respiratory rate
ectopic pregnancy
right lower quadrant abdominal tenderness
Risk factors of ectopic pregnancy
Any factor that compromises tubal patency
(STI’s,
assistive reproductive technologies,
tubal surgeries,
and contraceptive intrauterine devices)
A 35-year-old female is in labor. The baby is engaged in the pelvis. As the nurse, you know that this means that the fetal station is approximately?
A. +1 B. 0 C. +2 D. -1
B. O
Rationale: When a baby is engaged it means the presenting part of the baby (usually the head) has entered down into the pelvic inlet, and the presenting part is located at the ischial spines, which is fetal station 0.
When the mother’s membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?
A. Early decelerations
B. Variable decelerations
C. Nonperiodic accelerations
D. Increase in baseline variability
B. Variable Decelerations
Rationale: When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. Early declarations are considered reassuring; they are not a concern after rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Increase in baseline variability is not an expected occurrence after the rupture of membranes.
What is the most likely cause for this fetal heart rate pattern?
A. Administration of an epidural for pain relief during labor
B. Cord compression
C. Breech position of fetus
D. Administration of meperidine (Demerol) for pain relief during labor
B. Cord Compression
Rationale: Variable deceleration patterns are seen in response to head compression or cord compression. A breech presentation would not be likely to cause this fetal heart rate pattern. Similarly, administration of medication and/or an epidural would not cause this fetal heart rate pattern.
Use Nägele’s rule to determine the EDD (estimated day of birth) for a patient whose last menstrual period started on April 12.
A. February 19
B. January 19
C. January 21
D. February 7
B. January 19
When a pattern of variable decelerations occur, the nurse should immediately
A. administer O2 at 8 to 10 L/minute.
B Place a wedge under the right hip.
C. increase the IV fluids to 150 mL/hour.
D. position the patient in the knee-chest position.
D. position the patient in a knee chest position
Rationale: Variable decelerations are caused by conditions that reduce flow through the umbilical cord. The patient should be repositioned when the FHR pattern is associated with cord compression. The knee– chest position uses gravity to shift the fetus out of the pelvis to relieve cord compression. Administering oxygen will not be effective until cord compression is relieved. Increasing the IV fluids and placing a wedge under the right hip are not effective interventions for cord compression.
Variable decelerations of FHR Causes/complications
- umbilical cord compression
- short cord
- prolapsed cord
- nuchal cord (around fetal neck)
When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left side, which nursing action is indicated?
A. Lower the head of the bed.
B. Place a wedge under the left hip.
C. Change her position to the right side.
D. Place the mother in Trendelenburg position.
C. Change her position to the right side.
Rationale: A Category II pattern indicates an indeterminate fetal heart rate. Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta.
Lowering the head of the bed would not be the first position change choice. The woman is already on her left side, so a wedge on that side would not be an appropriate choice. Repositioning to the opposite side is the first intervention. If unsuccessful with improving the FHR pattern, further changes in position can be attempted; the Trendelenburg position might be the choice.
Which patients should get the alpha-fetoprotein test?
All pregnant women should be offered the AFP screening, but it is especially recommended for:
Women who have a family history of birth defects (AMA). Women who are 35 years or older. Women who used possible harmful medications or drugs during pregnancy.
What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?
a. Positive
b. Negative
c. Reactive
d. Nonreactive
C. Reactive
Rationale: The nonstress test (NST) is reactive (normal) when there are two or more fetal heart rate accelerations of at least 15 BPM (each with a duration of at least 15 seconds) in a 20-minute period. A positive result is not used with an NST. The contraction stress test (CST) uses positive as a result term. A negative result is not used with an NST. The CST uses negative as a result term. A nonreactive result means that the heart rate did not accelerate during fetal movement.
A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings?
A. NST positive, nonreassuring
B. NST negative, reassuring
C. NST reactive, reassuring
D. NST nonreactive, nonreassuring
C. NST Reactive, reassuring
Rationale: The presence of at least three accelerations of at least 15 beats, over at least 15 seconds, over a duration of at least 20 minutes, is considered reactive and reassuring. Nonreactive testing reveals no or fewer accelerations over the same or longer period. The NST test is not recorded as positive or negative.
if the FHR accelerates at least 15/min (10/min prior to 32 weeks) for at least 15 seconds (10 seconds prior to 32 weeks) and occurs two or more times during a 20 min period.
What is this reactive or non reactive?
Reactive
test does NOT demonstrate at least two qualifying accelerations in a 20-min window.
What is this reactive or non reactive?
NON reactive.
A pregnant patient is on magnesium sulfate. What should the nurse monitor for if performing an NST?
Monitor for adverse effect of nonreactive NST.
The nurse is assessing a patient in her 37th week of pregnancy for the psychological responses commonly experienced as birth nears. Which psychological responses should the nurse expect to evaluate? (Select all that apply.)
A. The patient is excited to see her baby.
B. The patient has not started to prepare the nursery for the new baby.
C. The patient expresses concern about how to know if labor has started.
D. The patient and her spouse are concerned about getting to the birth center in
E. The patient and her spouse have not discussed how they will share household tasks.
A. The patient is excited to see her baby
C. the patient expresses concern about how labor has started
D. the patient and her spouse are concerned about getting to the birth center in time
Rationale: As birth nears, the expectant patient will express a desire to see the baby. Most pregnant patients are concerned with their ability to determine when they are in labor. Many couples are anxious about getting to the birth facility in time for the birth. As birth nears, a nesting behavior occurs, which means getting the nursery ready. Not preparing the nursery at this stage is not a response that the nurse should expect to assess. Negotiation of tasks is done during this stage. Discussion regarding the division of household chores is not a response that the nurse should expect to assess at this stage.
A nurse in a clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?
A. Decreased vaginal discharge
B. A surge of energy
C. Urinary retention
D. Weight gain of 0.5 to 1.5 kg
B. A surge of energy
i: Prior to the onset of labor, the pregnant client experiences a surge of energy.
A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients?
A. A client who has mitral valve prolapse
B. A client who has been exposed to AIDS
C. All of the clients
D. A client who has a history of preterm labor.
C. All of the clients
i: MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman.
Physiologic changes preceding labor (premonitory signs)
- Backache
- Weight loss
- Lightening
- Contractions
- Increased vaginal discharge or bloody show
- Energy burst
- GI changes
- Cervical ripening
- Rupture of membranes
The nurse detects hypotension in a laboring patient after an epidural. Which actions should the nurse plan to implement? (Select all that apply.)
A. Encourage the patient to drink fluids.
B. Place the patient in a Trendelenburg position.
C. Administer a normal saline bolus as prescribed.
D. Administer oxygen at 8 to 10 L/minute per face mask.
E. Administer IV ephedrine in 5- to 10-mg increments as prescribed
C. Administer a normal saline bolus as prescribed.
D. Administer oxygen at 8 to 10 L/minute per face mask.
E. Administer IV ephedrine in 5- to 10-mg increments as prescribed
Rationale: If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The patient in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant patient.
Which of the following behaviors would be applicable to a nursing diagnosis of “risk for injury” in a patient who is in labor?
A. Length of second-stage labor is 2 hours.
B. Patient has received an epidural for pain control during the labor process.
C. Patient is using breathing techniques during contractions to maximize pain relief.
D. Patient is receiving parenteral fluids during the course of labor to maintain
hydration.
B. Patient has recieved an epidural for pain control during the labor process.
Rationale: A patient who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client’s blood pressure is 80/40 mmHg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?
A. Elevate the client’s legs.
B. Monitor vital signs every 5 min.
C. Notify the provider.
D. Place the client in a lateral position.
D. Place the client in a lateral position.
i: Based on Maslow’s hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client’s hips to relieve pressure on the inferior vena cava and improve the blood pressure.
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
A. Vomiting
B. Tachycardia
C. Respiratory depression
D. Hypotension
D. Hypotension
i: Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.
To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should
A. give the woman oxygen.
B. turn the woman to the right side.
C. decrease the intravenous infusion rate.
D. place a wedge under the woman’s right hip.
D. Place a wedge under the womans right hip
Rationale: Tilting the woman’s pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. Placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension.
A patient in active labor requests an epidural for pain management. What is the nurse’s most appropriate intervention at this juncture?
A. Assess the fetal heart rate pattern over the next 30 minutes.
B. Take the patient’s blood pressure every 5 minutes for 15 minutes.
C. Determine the patient’s contraction pattern for the next 30 minutes.
D. Initiate an IV Infusion of lactated ringers solution at 2000 ml/hour over 30 minutes
D. Initiate an IV Infusion of lactated ringers solution at 2000 ml/hour over 30 minutes
Rationale: Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringer’s or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation.
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse’s priority?
A. The client reports weakness of the lower extremities.
B. Blood pressure 80/56 mmHg
C. Temperature 38.2C / 100.8F
D. The client reports perfuse itching.
B. Blood pressure 80/56 mmHg
i: When using the airway, breathing, circulation approach to client care, the nurse’s priority finding is a blood pressure of 80/56, which indicates hypotension. The client’s blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death.
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?
A. Shortly after giving birth
B. In the third trimester
C. Immediately
D. During her next attempt to get pregnant
A. Shortly after giving birth
i: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?
A. The client is not experiencing a rubella infection at this time.
B. The client is immune to the rubella virus.
C. The client requires a rubella vaccination at this time.
D. The client requires a rubella immunization following delivery.
D. The client requires a rubella immunization following delivery.
i: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.
Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae?
a. Saturated perineal pad in 1 hour
b. Pain level 0 on a scale of 0 to 10
c. Cervical dilation at 2 cm
d. Fetal heart rate at 160 b
b. Pain level 0 on a scale of 0 to 10
What is the classic sign of placenta previa?
sudden onset of painless uterine bleeding during second or third trimester
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?
A. Drowsiness
B. Urinary output of 20 ml/hr
C. Normal deep tendon reflexes
D. Respiratory rate of 10 to 12 breaths per minute.
C. Normal deep tendon reflexes.
Rationale: Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium toxicity. A urinary output of 20 mL/hour is inadequate output. A respiratory rate of 10 to 12 breaths per minute is too slow and could be indicative of magnesium toxicity.
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer?
A. Protamine sulfate
B. Naloxone
C. Calcium gluconate
D. Flumazenil
C. Calcium gluconate
The nurse ahould discontinue the magnesium sulfate infusion immediately and prepare to administer calcium glucomate to reverse effects of magnesium sulfate to orevent fardiac and respiratory arrest
Signs of magnesium toxicity include the following:
- Respiratory rate of less than 12 breaths per minute (hospitals may specify a rate <14 breaths per minute)
- Urinary output less than 30 ml an hour
- Maternal pulse oximeter reading lower than 95%
- Absence of deep tendon reflexes
- Sweating, flushing
- Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented)
- Hypotension
The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
A. Cool, clammy skin
B. Altered sensorium
C. Pulse oximeter reading of 95%
D. Respiratory rate of less than 12 breaths per minute
E. Absence of deep tendon reflexes
B. Altered sensorium
D. Respiratory Rate…
E. Absence of deep tendon reflex
A nurse is assessing a client at 35 gestation who is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider?
A. Deep tendon reflex 2+
B. Blood pressure 150/96 mmHg
C. Urine output 20mL/hr
D. Respiratory rate 16/min
C. Urinary output 20mL/hr
The nurse should report urine output of 20mL/hr because this can indicate inadequate renal perfusion increasing the risk if magnesium sulfate toxicity
A nurse is assessing a client who is receiving magnesium sulfate as a treatment for preeclampsia. Which of the following clinical findings is the nurse’s priority?
A. Respirations
B. Urinary output 40 mL in 2 hr
C. Reflexes +2
D. Fetal heart rate 158/min
B. Urinary output 40 mL in 2 hour
Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue magnesium sulfate if the hourly output is <30mL/hr
A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.)
A. Respirations fewer than 12/min
B. Urinary output less than 30 mL/hr
C. Hyperreflexic deep-tendon reflexes
D. Decreased level of consciousness
E. Flushing and sweating
ABD
A nurse is administering magnesium sulfate IV for seizure prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? Select all that apply.
A. Respirations < 12/min
B. UOP < 25 mL/hr
C. Hyperreflexic DTR
D. Decreased LOC
E. Flushing and sweating
A, B, D - RR < 12/min, UOP < 25mL/hr, Decreased LOC
