A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.
She is not currently convulsing.
What intervention should the nurse plan to include in this client’s nursing care plan?
Monitor blood pressure, pulse, and respirations every 4 hours.
Keep an airway at the bedside.
Allow liberal family visitation.
Assess temperature every hour.
The Correct Answer is B
Choice A rationale
While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.
Choice B rationale
Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.
Choice C rationale
Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.
Choice D rationale
Assessing temperature every hour is not specifically related to the care of a client with eclampsia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While it’s true that phytonadione, also known as vitamin K, plays a role in the immune system, this is not the primary reason it is given to newborns. Therefore, this statement does not show an understanding of why the medication is being given.
Choice B rationale
Phytonadione does not aid an immature liver. It is necessary for the synthesis of certain proteins required for blood clotting. However, it does not directly aid the liver’s function.
Choice C rationale
This is the correct statement. Phytonadione is given to newborns to prevent hemorrhagic disorders, specifically vitamin K deficiency bleeding (VKDB). Newborns are at risk for VKDB because their gut does not yet have the bacteria necessary to produce vitamin K5.
Choice D rationale
While it’s true that vitamin K is obtained from dietary intake, newborns do not receive phytonadione to compensate for insufficient dietary intake. They receive it to prevent VKDB, a bleeding disorder caused by vitamin K deficiency.
Correct Answer is A
Explanation
Choice A rationale
In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.
Choice B rationale
While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.
Choice C rationale
Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.
Choice D rationale
Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.
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