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?

Choice A rationale

Bleeding is typically not associated with a vaginal hematoma; it is more indicative of other postpartum complications such as uterine atony or retained placenta fragments.

Choice B rationale

Warmth is usually associated with infection or inflammation. A hematoma is a collection of clotted blood outside the blood vessels, not typically characterized by warmth.

Choice C rationale

Redness might be seen in cases of infection or inflammation. A vaginal hematoma is a localized collection of blood and does not inherently cause redness.

Choice D rationale

Pain is a common symptom of a vaginal hematoma due to the pressure and swelling from the accumulated blood.

Choice A rationale

Assessing for vaginal bleeding in PPROM is generally not necessary unless there is an indication of placental issues or other complications. PPROM involves the rupture of membranes before 37 weeks, primarily requiring monitoring for infection and fetal wellbeing rather than routine bleeding checks.

Choice B rationale

Monitoring for signs of infection is critical after PPROM because the rupture increases the risk of ascending infections. The nurse should diligently assess for fever, foul-smelling discharge, and other signs of infection to initiate timely interventions, preserving both maternal and fetal health.

Choice C rationale

Checking for cervical dilation in PPROM is important because premature rupture of membranes can lead to preterm labor. Monitoring dilation helps determine if labor is imminent, influencing decisions regarding maternal and neonatal care to prevent complications from premature birth.

Choice D rationale

Watching for fetal compromise is necessary following PPROM as premature rupture of membranes can lead to umbilical cord compression or other complications affecting fetal oxygenation. Continuous fetal monitoring helps detect early signs of distress, allowing timely intervention to ensure fetal safety.