Which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor?
Client will be infection free at discharge.
Client will exhibit normal breathing function at discharge.
Client will exhibit normal gastrointestinal function at discharge.
Client will void without pain at discharge.
The Correct Answer is B
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.
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Correct Answer is D
Explanation
Choice A rationale
Reduction of fever is not a primary effect of carboprost tromethamine. This medication is primarily used to induce uterine contractions to manage postpartum hemorrhage.
Choice B rationale
While maintaining stable blood pressure is important, it is not the specific indicator of carboprost tromethamine's effectiveness. This medication is used to control bleeding.
Choice C rationale
Increased comfort, although significant, is not the direct effect of carboprost tromethamine. The primary aim is to induce uterine contractions to manage hemorrhage.
Choice D rationale
Decreased lochia rubra indicates the reduction of postpartum bleeding, which is the primary purpose of administering carboprost tromethamine. This outcome shows the medication is effective.
Correct Answer is D
Explanation
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.