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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

PTB is the leading cause of neonatal mortality and for antenatal hospitalization. This is accurate because preterm birth (PTB) is a significant cause of infant mortality and often

requires extended hospital stays for the management of complications.

Choice B rationale

PTBs result in increased numbers of neonatal and infant deaths and long-term neurological impairment. This is accurate because preterm births are associated with higher rates of

mortality and long-term health issues in infants.

Choice C rationale

PTL is defined as regular uterine contractions resulting in cervical changes before 37 weeks gestation. This is accurate because preterm labor (PTL) is indeed characterized by these

symptoms occurring before full-term pregnancy.

Choice D rationale

Average costs for premature/low birthweight infants are more than 10 times as high than for other newborns. This is accurate because medical care for premature and low

birthweight infants is significantly more expensive due to the need for specialized care and extended hospital stays.

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.

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