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
Explanation
Choice A rationale
Contraction duration less than 40 seconds doesn't define tachysystole. Tachysystole focuses on frequency, not duration, of contractions over a specific time frame.
Choice B rationale
Contraction frequency of more than 5 in 10 minutes defines tachysystole. This frequency indicates excessive uterine activity, requiring intervention to prevent fetal distress.
Choice C rationale
Contraction intensity less than 80 mm Hg does not define tachysystole. Intensity relates to contraction strength, but tachysystole is about frequency exceeding the normal range.
Choice D rationale
Resting tone less than 18 mm Hg isn't part of tachysystole's definition. Tachysystole pertains to contraction frequency, not resting tone, which measures uterine relaxation between contractions.
Correct Answer is C
Explanation
Choice A rationale
Prolonged labor is not directly linked to drug use and does not present as an immediate complication.
Choice B rationale
Prolapsed cord is not associated with substance abuse and lacks direct connection to this scenario.
Choice C rationale
Cocaine use heightens the risk of abruptio placentae, a serious condition where the placenta detaches prematurely.
Choice D rationale
Retained placenta is a concern but less likely than abruptio placentae in the context of cocaine use.