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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?

A.

Respiratory rate is 18 breaths/min.

B.

Urinary output remains at 30 mL/hr.

C.

Patella reflexes are rated at one.

D.

Serum magnesium level is 10 mg/dL. . .

Answer and Explanation

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 D

Explanation

Choice A rationale

Checking the blood sugar of a gestational diabetic is essential but not immediately life-threatening. Blood sugar levels should be monitored regularly throughout pregnancy for

diabetics to prevent complications. However, this does not represent an urgent priority when compared to the other options, which involve more immediate risks to life and health.

Choice B rationale

Assessing vaginal blood loss in a client recovering from a spontaneous abortion is crucial to monitor for hemorrhage or infection. Heavy bleeding could signal a serious complication

needing immediate intervention, though it is not the most immediate priority over monitoring fetal heart rate during active labor.

Choice C rationale

Monitoring the patellar reflexes of a client with pre-eclampsia without severe features can help in detecting early signs of progressing pre-eclampsia. While important, it is generally

not as critical as ensuring immediate fetal wellbeing, especially if reflexes do not present signs of worsening.

Choice D rationale

Checking the fetal heart rate in a client whose membranes have just ruptured is paramount. Rupture of membranes could lead to immediate complications such as umbilical cord

prolapse, leading to rapid fetal distress. Therefore, verifying fetal heart rate ensures that the fetus is not in immediate danger.

Correct Answer is B

Explanation

Choice A rationale

Administering oxytocin during shoulder dystocia can exacerbate the problem by increasing uterine contractions, making it harder to deliver the baby's shoulder.

Choice B rationale

Flexing the client's thighs sharply toward her abdomen, known as the McRoberts maneuver, helps to widen the pelvis and can often resolve shoulder dystocia by changing the angle of the pelvic bones.

Choice C rationale

While applying oxygen is a standard practice to improve maternal and fetal oxygenation, it does not specifically address shoulder dystocia and is not a primary intervention.

Choice D rationale

Applying downward pressure on the fundus is contraindicated as it can worsen shoulder dystocia by further impacting the shoulder against the pelvic bone.

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