Maternity Nursing: Antepartum Q 9
A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse?
A. Urinary output of 20 ml since the previous assessment
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 BPM
D. Fetal heart rate of 120 BPM
Correct Answer: C. Respiratory rate of 10 BPM.
Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed.
Option A: A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. The kidneys face remarkable demands during pregnancy, and it is critical that the practicing nephrologist understands the normal kidney adaptations to pregnancy. GFR rises early to a peak of 40% to 50% that of prepregnancy levels, resulting in lower levels of serum creatinine, urea, and uric acid. There is a net gain of sodium and potassium, but a greater retention of water, with gains of up to 1.6 L.
Option B: Deep tendon reflexes of 2+ are normal. With preeclampsia, a woman’s reflexes become unusually active. Increasing blood pressure will lead to increasing hyperreflexia until uncontrollable seizures eventually result. Testing for this change is difficult in the field setting; in a clinic setting an overactive patellar response is a good indicator.
Option D: The fetal heart rate is WNL for a resting fetus. Current international guidelines recommend for the normal fetal heart rate (FHR) baseline different ranges of 110 to 150 beats per minute (bpm) or 110 to 160 bpm.