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 C
Explanation
Choice A rationale
Magnesium sulfate is primarily used for neuroprotection in preterm infants and to prevent seizures in severe preeclampsia, not as a first-line tocolytic for preterm labor.
Choice B rationale
Morphine sulfate is an opioid analgesic used for pain management, not for inhibiting preterm labor contractions.
Choice C rationale
Terbutaline is a beta-agonist used as a tocolytic to relax uterine muscles and delay preterm labor. It helps decrease the intensity and frequency of contractions, making it suitable for managing preterm labor.
Choice D rationale
Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not for direct contraction inhibition.
Correct Answer is B
Explanation
Choice A rationale
Induction timing is secondary to assessing readiness. The Bishop score determines cervical favorability for induction success.
Choice B rationale
The Bishop score assesses cervical readiness for labor induction, which is vital in planning an effective induction.
Choice C rationale
Refusal to induce without considering clinical data is inappropriate. The Bishop score evaluation determines readiness.
Choice D rationale
Prostaglandin preparation follows Bishop score assessment to ensure induction safety and efficacy.