A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via

continuousIV infusion forsevere pre-eclampsia. Which of the following findings should the nurse report

to the provider?

Urinary output 20 mL/hr;

The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal

perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also

indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.

A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The nurse notes that

the client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type

of O negative. Which of the following actions should the nurse take?

Instructthe client to obtain rubella immunization after delivery;

This client is not immune to rubella and should receive thisimmunization after delivery.

A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental abruption. Which of

the following findings should the nurse expect?

Dark red vaginal bleeding;

The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal

bleeding.

A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential

effects of the fibroid during pregnancy. Which of the following information should the nurse include in

the teaching?

The fibroid can increase the risk for postpartum hemorrhage;