A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?

Place the client in a Trendelenburg position.

Assist the client to void.

Administer oxygen to the client via face mask at 10 L/min.

Give calcium gluconate to the client.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Placing the client in a Trendelenburg position (head down and feet up) is not recommended after a convulsion in a pregnant client. It could potentially compromise blood flow to the brain and fetus. The priority after a convulsion is to ensure the client's airway and oxygenation.

Choice B rationale:
Assisting the client to void might be necessary during the course of care but is not the immediate action needed after a convulsion. The priority is to address airway and oxygenation needs.

Choice C rationale:
Administering oxygen to the client via face mask at 10 L/min is the correct action after the client experiences a convulsion. Eclampsia is a severe complication of preeclampsia, characterized by seizures. Providing oxygen ensures adequate oxygenation to the brain and vital organs during and after the convulsion.

Choice D rationale:
Giving calcium gluconate is not the appropriate action for eclampsia. Calcium gluconate is used to treat hyperkalemia and calcium channel blocker overdose. It does not address the underlying issue of eclampsia or prevent further convulsions. The immediate focus should be on managing the convulsions and ensuring the client's safety and well-being.

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Correct Answer is B

Explanation

Choice A rationale:

Swaddling the baby tightly with his legs extended before laying him down to sleep is not a recommended practice, as it can increase the risk of hip dysplasia. Instead, the baby should be placed on their back in a safe sleep environment.

Choice B rationale:

This statement is correct because monitoring the baby's urinary output is essential in ensuring adequate hydration and proper kidney function. Less than six wet diapers a day could be a sign of dehydration and should be promptly reported to the pediatrician.

Choice C rationale:

It is not necessary to retract the foreskin to clean the baby's penis during each bath. The foreskin should be left alone and not forcibly retracted until it naturally loosens, usually around the age of 3 to 5 years.

Choice D rationale:

Applying triple antibiotic ointment on the baby's umbilical cord is not recommended, as the standard practice is to keep the umbilical cord clean and dry. This helps it to fall off naturally within a week or two after birth, reducing the risk of infection.

A. Avoid using lotion or ointment on the newborn's skin. B. Dress the newborn in lightweight clothing. C. Keep the newborn supine throughout treatment. D. Measure the newborn's temperature every 6 hr.

Correct Answer is A

Explanation

Choice A rationale:

When a newborn is receiving phototherapy for hyperbilirubinemia, it is essential to avoid using lotions or ointments on the skin. Phototherapy works by breaking down bilirubin in the skin, and any barriers like lotions or ointments can interfere with this process. The baby's skin needs to be exposed to the light to effectively reduce bilirubin levels.

Choice B rationale:

Dressing the newborn in lightweight clothing is a correct action during phototherapy. The baby should be undressed and placed under the phototherapy lights, with only a diaper on to maximize skin exposure to the light.

Choice C rationale:

Keeping the newborn supine throughout treatment is not a recommended action during phototherapy. To optimize skin exposure to the light, the baby should be placed in a prone position, with the back exposed to the light source.

Choice D rationale:

Measuring the newborn's temperature every 6 hours is essential, but it is not directly related to phototherapy. Temperature monitoring is a routine part of newborn care to assess for signs of infection or other health issues.

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A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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