The nurse is providing care to a postpartum patient after an emergency cesarean due to eclampsia. The patient received spinal anesthesia before delivery. Magnesium sulfate is infusing 2 g/hr in 100 mL of IV fluid.
Which assessment finding will cause the nurse to administer calcium gluconate to the patient via IV push?
Respiratory rate is 18 breaths/min.
Urinary output remains at 30 mL/hr.
Patella reflexes are rated at one.
Serum magnesium level is 10 mg/dL. . .
The Correct Answer is D
Choice A rationale
A respiratory rate of 18 breaths/min is normal and does not indicate magnesium toxicity or the need for calcium gluconate.
Choice B rationale
Urinary output of 30 mL/hr is within the acceptable range and does not suggest magnesium toxicity. This indicates adequate renal function.
Choice C rationale
Patellar reflexes rated at one indicate mild hyporeflexia, which can be a side effect of magnesium sulfate but does not necessitate immediate intervention.
Choice D rationale
Serum magnesium level of 10 mg/dL is significantly elevated, indicating magnesium toxicity. Calcium gluconate is the antidote for magnesium toxicity and should be administered
promptly to prevent severe complications.
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Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Pumping up the vacuum manually to the pressure indicated on the pump is a standard procedure but doesn't directly minimize liability.
Choice B rationale
Recognizing cup detachment (pop off) as a warning sign is critical, as it indicates excessive force or poor positioning, which can lead to fetal or maternal injury.
Choice C rationale
Limiting the cup's attachment to the fetal head to 5 to 10 minutes reduces the risk of scalp injury and other complications, thus minimizing liability.
Choice D rationale
Timing the procedure from insertion of the cup into the vagina until the birth is a guideline but doesn't specifically address liability concerns.
Choice E rationale
Releasing pressure between contractions prevents continuous suction on the fetal head, reducing the risk of injury and thereby minimizing liability.
Correct Answer is C
Explanation
Choice A rationale
Decreased pain level can be an effect of addressing the cause of pain, but it doesn't indicate improved uterine tone or resolution of atony.
Choice B rationale
Stable blood pressure is important, but it is not the direct outcome of improved uterine tone or the resolution of uterine atony.
Choice C rationale
A firm fundus at or below the umbilicus indicates successful contraction of the uterus, resolving uterine atony and reducing bleeding.
Choice D rationale
Reduced lochial flow can indicate decreased bleeding, but it does not directly indicate improved uterine tone or resolution of uterine atony.