A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?

Choice A rationale

Caput succedaneum is a benign swelling of the soft tissues of the scalp that crosses suture lines and does not require drainage.

Choice B rationale

Cephalhematoma is a collection of blood between the skull and periosteum that does not cross suture lines; it may contribute to jaundice as it is reabsorbed by the body.

Choice C rationale

While cephalhematoma usually resolves without intervention, it is important to monitor for potential complications, including jaundice, due to the breakdown of red blood cells.

Choice D rationale

Caput succedaneum typically resolves on its own without intervention, as the fluid is gradually absorbed by the body over time.

Choice A rationale

Explaining procedures is important for patient understanding and consent, but it does not directly stabilize the client's condition during an eclamptic seizure.

Choice B rationale

Treating nausea can provide symptomatic relief but does not address the primary concerns of airway protection, seizure control, and hemodynamic stability in eclamptic patients.

Choice C rationale

Ensuring side rails are padded prevents injury during seizures by providing a protective barrier, reducing the risk of trauma from uncontrolled movements.

Choice D rationale

Assisting with breast pumping does not directly impact the stabilization of an eclamptic patient. The priority is managing seizures and ensuring patient safety.

Choice E rationale

Evaluating blood pressure frequently allows for early detection of hypertension or hypotension, guiding appropriate interventions to maintain hemodynamic stability and prevent complications.

Choice F rationale

Evaluating for headache is important for assessing potential complications of eclampsia, such as intracranial hypertension, but does not directly stabilize the patient during an acute seizure.

Choice G rationale

Assessing deep tendon reflexes helps monitor neurological status and the effectiveness of magnesium sulfate therapy, guiding further treatment decisions to prevent complications.

Choice H rationale

Minimizing visitors reduces environmental stimuli, which can help lower stress levels and prevent triggering additional seizures, contributing to the patient's stabilization.