Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
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?
Correct answer
A
Rationale
The correct answer is A: Urinary output 40 mL in 2 hr. This is the nurse's priority as it indicates potential renal impairment or inadequate perfusion, necessitating immediate intervention to prevent further complications. A decreased urinary output can lead to electrolyte imbalances, fluid overload, and organ damage. Monitoring and addressing urinary output promptly is crucial in maintaining homeostasis.
The other choices are less critical:
B: Fetal heart rate 158/min - important for monitoring fetal well-being but not the priority in this scenario.
C: Reflexes +2 - a normal finding and not urgent.
D: Respirations 16/min - within normal range and does not require immediate attention.
The other choices are less critical:
B: Fetal heart rate 158/min - important for monitoring fetal well-being but not the priority in this scenario.
C: Reflexes +2 - a normal finding and not urgent.
D: Respirations 16/min - within normal range and does not require immediate attention.