At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?

Start prescribed IV with lactated Ringer's.

Inform the anesthesia care provider.

Contact the client's obstetrician.

Ensure preoperative lab results are available.

Answer and Explanation

The Correct Answer is B

Choice B rationale

Informing the anesthesia care provider is the priority action. Ingesting coffee within a few hours before surgery can affect anesthesia management, and the anesthesia team needs to be aware of any potential complications.

Choice A rationale

Starting the IV is important but not the priority in this scenario. The anesthesia care provider needs to be informed first.

Choice C rationale

Contacting the obstetrician is also important but comes after informing the anesthesia care provider.

Choice D rationale

Ensuring preoperative lab results are available is essential, but the first step should be to inform the anesthesia care provider about the coffee intake.

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Correct Answer is ["A","C","D","E","G"]

Explanation

Choice A rationale

Increasing IV fluids is a critical intervention to maintain maternal hemodynamic stability and prevent complications related to fluid imbalance. It helps support blood pressure and overall fluid status during labor and delivery.

Choice B rationale

While obtaining blood pressure is important for monitoring maternal status, it is not an immediate intervention compared to others listed. Blood pressure monitoring is part of routine assessment but not an emergency action.

Choice C rationale

Stopping the infusion of magnesium is essential if there are signs of magnesium toxicity or adverse effects. Magnesium can impact respiratory and cardiac function, so stopping the infusion is a priority.

Choice D rationale

Administering oxygen is an immediate intervention to ensure adequate oxygenation for both the mother and the fetus. It is crucial during labor and delivery to prevent hypoxia and related complications.

Choice E rationale

Obtaining serum magnesium level is necessary to assess for magnesium toxicity and guide further interventions. It provides important information on the mother's magnesium status and helps in making clinical decisions.

Choice F rationale

Preparing for a cesarean delivery is not an immediate intervention unless there are specific indications for surgical delivery. It should be based on clinical findings and maternal-fetal status.

Choice G rationale

Administering calcium gluconate is the antidote for magnesium toxicity and is an immediate intervention if signs of toxicity are present. It helps counteract the effects of excessive magnesium.

Choice H rationale

Preparing to prevent respiratory or cardiac arrest is a critical intervention in severe cases of magnesium toxicity, but it should be part of a broader emergency management plan rather than an immediate action. .

Correct Answer is ["50"]

Explanation

Step 1 is (2 grams/hour ÷ 20 grams) × 500 mL.

Step 2 is (2 ÷ 20) × 500.

Step 3 is 0.1 × 500. The final calculated answer is 50 mL/hour.

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At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

Correct Answer is ["A","C","D","E","G"]

Explanation

Correct Answer is ["50"]

Explanation

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At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?