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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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Postpartum psychosis poses significant risks to both the mother and her infant. The mother may have impaired judgment, hallucinations, or delusions, making it unsafe for her to be

left alone with her baby.

Choice B rationale

Symptoms of postpartum psychosis can persist for several weeks to months without appropriate treatment. Immediate and ongoing intervention is crucial to manage the condition.

Choice C rationale

Clinical response to medications for postpartum psychosis can vary, but with proper treatment, many clients show significant improvement. It is not accurate to state that the

response is usually poor.

Choice D rationale

While monitoring vitals may be part of overall care, it is not the most critical teaching point. Ensuring the mother is never left alone with her infant is essential to prevent potential

harm.

Correct Answer is B

Explanation

Choice A rationale

Retained tissue can cause postpartum hemorrhage, but with a firm uterus and no other signs of retained placenta, this is less likely the cause here.

Choice B rationale

Trauma is the most likely cause of increased bleeding in this scenario. The prolonged oxytocin induction and macrosomic infant suggest a higher risk of lacerations or uterine atony

despite the firm uterus.

Choice C rationale

Thrombin disorders cause bleeding due to clotting issues. However, this patient shows signs of active bleeding and clotting, making this less likely.

Choice D rationale

Uterine atony, indicated by a soft, boggy uterus, is a common cause of postpartum hemorrhage, but in this case, the uterus is firm, so it's less likely to be the cause.

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