A nurse is assessing a client with eclampsia who is having a seizure.
Which of the following actions should the nurse take first?
Turn the client to the side
Insert an oral airway
Administer oxygen via face mask
Document the duration of the seizure
The Correct Answer is A
Turn the client to the side. This is because turning the client to the side will prevent aspiration and maintain a patent airway during a seizure.
Some possible explanations for the other choices are:
• Choice B. Insert an oral airway. This is wrong because inserting an oral airway during a seizure can cause injury to the client’s mouth or teeth, and it can also stimulate the gag reflex and increase the risk of vomiting and aspiration.
• Choice C. Administer oxygen via face mask. This is wrong because administering oxygen via face mask during a seizure can be difficult and ineffective, as the client may not be able to breathe through the mask or may dislodge it with their movements. Oxygen can be given after the seizure has stopped, if needed.
• Choice D. Document the duration of the seizure.
This is wrong because documenting the duration of the seizure is not a priority action during a seizure. The nurse should first ensure the client’s safety and airway patency, and then document the seizure characteristics after it has ended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
“This medication will help my baby’s lungs develop faster.” Corticosteroid therapy is given to pregnant clients with eclampsia to accelerate fetal lung maturity and reduce the risk of respiratory distress syndrome in the newborn.
Some possible explanations for the other choices are:
• Choice A is wrong because corticosteroids do not lower blood pressure.Antihypertensive drugs such as hydralazine or labetalol are used to treat hypertension in eclampsia.
• Choice B is wrong because corticosteroids do not prevent seizures.Magnesium sulfate is the drug of choice for seizure prophylaxis and treatment in eclampsia.
• Choice D is wrong because corticosteroids do not reduce inflammation in the body.They may have anti-inflammatory effects in some conditions, but their main purpose in eclampsia is to enhance fetal lung development.
Normal ranges for blood pressure and proteinuria in pregnancy are:
• Blood pressure: less than 140/90 mm Hg
• Proteinuria: less than 300 mg/24 hours or less than 1+ on dipstick
Correct Answer is C
Explanation
C. Fetal heart rate decelerations.
Fetal heart rate decelerations are temporary drops in the fetal heart rate that can indicate fetal distress or lack of oxygen.There are three types of decelerations: early, late and variable.Early decelerations are benign and caused by compression of the fetus’s head during a uterine contraction.Late decelerations are caused by uteroplacental insufficiency, which is a decrease in blood flow to the placenta.Variable decelerations are the most common type and vary in shape, duration and intensity.They are often caused by cord compression or other factors that affect fetal oxygenation.
•
A. Fetal heart rate of 140 beats per minute.
Statement is wrong because this is a normal fetal heart rate.The normal range for fetal heart rate is 120-160 beats per minute.
•
B. Uterine contractions every 10 minutes.
Statement is wrong because this is a normal frequency for uterine contractions during early labor.
The normal range for uterine contractions is 5-10 minutes apart.
•
D. Uterine contractions lasting 60 seconds.
Statement is wrong because this is a normal duration for uterine contractions during active labor.
The normal range for uterine contractions is 45-90 seconds long.
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