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
The hemoglobin level of 11.6 g/dL is within the normal range for a pregnant woman. While placenta previa requires monitoring, it is not immediately life-threatening.
Choice B rationale
Type 2 diabetes mellitus requires regular monitoring and management, but a single fasting blood glucose level does not indicate an immediate emergency unless it is extremely high or low.
Choice C rationale
Partial placental abruption can lead to significant complications for both the mother and fetus, including hemorrhage and fetal distress, making it the priority for immediate assessment.
Choice D rationale
An Rh-negative status and a recent cerclage placement are important for ongoing monitoring but do not present an immediate life-threatening condition that demands the first assessment.
Correct Answer is B
Explanation
Choice A rationale
Applying ice packs can help reduce pain and swelling, but it is not the best intervention for a breastfeeding mother with mastitis. Ice can constrict blood vessels and may hinder milk
flow, which can exacerbate the condition.
Choice B rationale
Frequent breastfeeding helps to empty the affected breast and prevent milk stasis, reducing the risk of abscess formation and promoting faster healing. The mechanical action of
nursing can help clear the infection and provide relief.
Choice C rationale
Weaning immediately is not advised as it can lead to engorgement and milk stasis, worsening the infection. Continuing to breastfeed ensures the breast is regularly emptied, aiding
in recovery.
Choice D rationale
While notifying the pediatrician may be necessary if the baby is affected, it does not directly address the mother's condition or provide immediate relief. Primary management focuses
on treating the infection and maintaining milk flow.