Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

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.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is B

Explanation

Choice A rationale

Prior amniotic fluid leakage is not a required criterion for amniotomy. The main concern is cervical readiness and fetal head position, not previous leakage.

Choice B rationale

The fetal head engaged in the maternal pelvis ensures proper pressure and position for safe amniotomy. Engagement reduces the risk of umbilical cord prolapse and injury.

Choice C rationale

Certification of the nurse for amniotomy is not a standard criterion. The procedure is performed by qualified professionals, but certification isn't a prerequisite for the procedure to be scheduled.

Choice D rationale

Ultrasound to check the umbilical cord's position isn't a standard pre-amniotomy criterion. While it can be useful, the primary concern is the fetal head engagement and cervical readiness.

Correct Answer is B

Explanation

Choice A rationale

While infection prevention is vital, ensuring breathing function is more critical after ASP.

Choice B rationale

ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.

Choice C rationale

Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.

Choice D rationale

Voiding without pain is important, but respiratory stability takes precedence.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2025, All Right Reserved.