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
Prior amniotic fluid leakage is not a required criterion for amniotomy. The main concern is cervical readiness and fetal head position, not previous leakage.
Choice B rationale
The fetal head engaged in the maternal pelvis ensures proper pressure and position for safe amniotomy. Engagement reduces the risk of umbilical cord prolapse and injury.
Choice C rationale
Certification of the nurse for amniotomy is not a standard criterion. The procedure is performed by qualified professionals, but certification isn't a prerequisite for the procedure to be scheduled.
Choice D rationale
Ultrasound to check the umbilical cord's position isn't a standard pre-amniotomy criterion. While it can be useful, the primary concern is the fetal head engagement and cervical readiness.
Correct Answer is B
Explanation
Choice A rationale
While infection prevention is vital, ensuring breathing function is more critical after ASP.
Choice B rationale
ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.
Choice C rationale
Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.
Choice D rationale
Voiding without pain is important, but respiratory stability takes precedence.