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.

Answer and Explanation

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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Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.

Correct Answer is ["6"]

Explanation

The correct answer is calculated as follows:

Step 1: Identify the total amount of oxytocin in the IV bag. The bag contains 20 units of oxytocin in 1 liter (or 1000 mL) of lactated Ringer’s solution.

Step 2: Convert the oxytocin units to milliunits. 1 unit = 1000 milliunits, so 20 units = 20,000 milliunits.

Step 3: Calculate the concentration of the oxytocin solution in milliunits/mL. Divide the total amount of oxytocin in milliunits by the total volume of the solution in mL.

So, 20,000 milliunits ÷ 1000 mL = 20 milliunits/mL.

Step 4: Calculate the infusion rate in mL/hour. The prescription is for an infusion rate of 2 milliunits/min. Since the concentration of the solution is 20 milliunits/mL, we divide the prescribed rate by the concentration to get the rate in mL/min. So, 2 milliunits/min ÷ 20 milliunits/mL = 0.1 mL/min.

Step 5: Convert the infusion rate to mL/hour. Multiply the rate in mL/min by the number of minutes in an hour. So, 0.1 mL/min × 60 min/hour = 6 mL/hour. Therefore, the nurse should program the infusion pump to deliver 6 mL/hour.

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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?

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Naxlex Comprehensive Predictor Exams

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer’s 1 liter. How many mL/hour should the nurse program the infusion pump to deliver? .

Correct Answer is ["6"]

Explanation

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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?