NursingPlex
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    Ati rn comprehensive predictor 2023 retake proctored exam
    Select All That Apply

    The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits The nurse is evaluating the client's response to interventions. Click to highlight the findings that indicate the client's condition has improved. To deselect a finding, click on the finding again. Vital Signs 1800: Temperature 38.3° C(101° F) Heart rate 58/min Blood pressure 146/96 mm Hg Oxygen saturation 95% on 2 L nasal cannula Nurses Notes 1800: DTR 2+ bilaterally Urine output 40mL in the last hour

    Explanation & Rationale

    Rationale for correct choices: DTR 2+ bilaterally: This is within the normal range and shows recovery from previous central nervous system depression caused by magnesium sulfate toxicity, which earlier caused a drop to 1+. Urine output 40 mL in the last hour: Output is improving from the prior 20 mL/hr, suggesting better renal perfusion and clearance of magnesium. Adequate urine output is critical to prevent accumulation and toxicity. Oxygen saturation 95% on 2 L nasal cannula: This value meets the prescribed goal and reflects stabilized respiratory function after earlier shallow breathing. It indicates successful oxygenation support. Rationale for incorrect choices: Temperature 38.3° C (101° F): This is an elevated temperature and may indicate systemic infection or inflammation. It does not support an improvement in condition and warrants monitoring. Heart rate 58/min: This is bradycardia and could indicate lingering effects of magnesium toxicity or a vagal response. It does not reflect improvement and needs further assessment. Blood pressure 146/96 mm Hg: Although slightly lower than the earlier reading of 170/112 mm Hg, it is still in the hypertensive range and does not signify resolution of preeclampsia or stabilization.

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