The nurse is assisting in the care of the client who is at 30 weeks of gestation. Nurses’ Notes
1200:
Provided a quiet environment, dimmed the lights, and encouraged client to remain in bed in the side-lying position.
Encouraged client to cough and take deep breaths regularly.
Assisted with insertion of 18-gauge IV and initiation of IV fluid.
Assisted with insertion of indwelling urinary catheter per provider prescription. Maintained strict 180.
FHR 136/min via external fetal monitor. Minimal variability noted, no contractions present.
1400:
Client is lethargic. Heart rate regular, respirations shallow DTR 1+ bilaterally.
Urine output 20 mL in the last hour
1405:
Assists with discontinuation of magnesium sulfate infusion Notifies provider of client status.
1800:
Client is alert and responsive. Heart rate regular respirations even and unlabored. DTR 2- bilaterally
Oxygen saturation (SaO) 95% on 2 L nasal cannula Respiratory rate 18/min
Select the findings that indicate the client’s condition has improved.
A.
Urine pupus 40 mL in the last hour
B.
Temperature 38.3″ C(101 F)
C.
Blood pressure 146/96 mm Hg
D.
Urine output 40 mL
E.
Deep tendon reflexes 2+ bilaterally
F.
Heart rate 58/min
The correct answer and Explanation is :
The findings that indicate the client’s condition has improved are:
D. Urine output 40 mL
E. Deep tendon reflexes 2+ bilaterally
Explanation:
Urine Output:
In the initial notes, the client’s urine output was 20 mL in the last hour, which is quite low and concerning, as it can indicate potential issues with kidney function or fluid balance. By 1800, if the urine output had increased to 40 mL in the last hour, this suggests an improvement in renal function and better fluid balance, especially following the discontinuation of magnesium sulfate. Magnesium sulfate can affect kidney function, and an increase in urine output is a positive sign of recovery.
Deep Tendon Reflexes (DTRs):
Initially, the client had DTRs of 1+ bilaterally, which indicates diminished reflexes and could be a sign of magnesium sulfate toxicity or other neurological concerns. By 1800, the DTRs had improved to 2+ bilaterally, which is considered a normal finding. This improvement suggests that the client’s neurological status is stabilizing and that there might be a reduction in symptoms related to magnesium sulfate toxicity or other underlying conditions.
Not Selected Findings:
- A. Urine output 40 mL in the last hour (While this is indeed an improvement, the exact figure of urine output at 1400 wasn’t provided, so the change to 40 mL can’t be confirmed as the only improvement.)
- B. Temperature 38.3°C (101°F) (A fever of 38.3°C indicates a potential infection or other complications, not an improvement.)
- C. Blood pressure 146/96 mm Hg (This blood pressure reading is elevated, suggesting possible hypertension or other issues, not an improvement.)
- F. Heart rate 58/min (A heart rate of 58/min could be bradycardia and may indicate a problem if it’s not within the client’s normal range.)
Overall, the increase in urine output and the normalization of deep tendon reflexes are the most direct indicators of improvement in the client’s condition.