A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?

Monitor blood pressure pulse, and respirations every 4 hour

Keep an airway at the bedside

Allow liberal family visitation

Assess temperature every hour

Answer and Explanation

The Correct Answer is B

A. Monitor blood pressure, pulse, and respirations every 4 hours: Monitoring vital signs is important, especially in a client with eclampsia. However, the frequency of monitoring may need to be increased, particularly if the client's condition is unstable.

B. Keep an airway at the bedside: This is a crucial intervention. Eclampsia can lead to seizures, and having airway management equipment readily available is essential to ensure the client's safety during and after a seizure.

C. Allow liberal family visitation: While family support is important, the priority in eclampsia management is the safety and well-being of the client. Family visitation should be allowed, but it may need to be balanced with the need for a controlled and safe environment.

D. Assess temperature every hour: While monitoring temperature is a part of routine care, it may not be the highest priority in the context of eclampsia. Monitoring for signs of imminent seizure activity and maintaining a safe environment take precedence.

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Correct Answer is C

Explanation

A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.

B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.

C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.

D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.

A. After ceasing breastfeeding the diaphragm should be resized. B. Use an alternate form of contraception until a new diaphragm is obtained. C. If no more than 20 pounds was gained during pregnancy, the diaphragm is safe to use. D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated

Correct Answer is B

Explanation

A. After ceasing breastfeeding, the diaphragm should be resized: Breastfeeding can affect vaginal lubrication and elasticity. It might be advisable to have the diaphragm refitted after childbirth and after breastfeeding stops. However, this choice doesn't directly address the current situation.

B. Use an alternate form of contraception until a new diaphragm is obtained: This is a reasonable suggestion. Using a diaphragm that was fitted before pregnancy might not offer adequate protection due to potential changes in the cervix's size or shape after childbirth.

C. If no more than 20 pounds were gained during pregnancy, the diaphragm is safe to use: Weight gain during pregnancy can affect the size and shape of the vagina and cervix. However, specifying a particular weight gain as a safety criterion for using the diaphragm isn't entirely accurate.

D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated: This is a cautious approach. Waiting until the diaphragm size is confirmed by a healthcare professional could be prudent to ensure the correct fit and effectiveness.

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A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?

Correct Answer is B

Explanation

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