题目：
A gravida 2, para 1 with pregnancy-induced hypertension is receiving magnesium sulfate IV, 2g/hour via infusion pump. In assessing the client, the nurse notes a decrease in respirations from 16 to 12 breaths/minute and slightly pink-tinged urine (output is 25mL/hour). The client still complains of feeling sleepy. The nurse’s action should include
A. checking the most recent serum level of magnesium sulfate and notifying the physician of the results.
B. turning the client on her left side and taking vital signs again.
C. flushing the client’s indwelling urinary catheter with sterile normal saline solution to see if it’s draining properly.
D. instructing the client to turn, cough, and deep breathe every 30 minutes.
答案：
参考答案：A
解析：Urine that is scant (less than 30 mL/hour) and tinged with blood indicates potential renal damage and must be reported to the physician. Turning the client on her left side and taking vital signs increases blood perfusion to the uterus. Flushing the client’s indwelling urinary catheter is unnecessarily invasive and doesn’t address the blood-tinged urine. Instructing the client to turn, cough, and deep breathe every 30 minutes has nothing to do with the client’s symptoms.
