A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure.
Which of the following actions should the nurse take following the seizure.
Initiate an amnioinfusion.
Apply an internal fetal heart monitor.
Administer calcium gluconate via IV bolus.
Place the client on her side.
The Correct Answer is D
Choice A rationale
Amnioinfusion is the infusion of saline into the amniotic cavity. It is used to treat umbilical cord compression or meconium staining, not to manage seizures. Initiating an amnioinfusion during a seizure would be an inappropriate and ineffective intervention that would not address the underlying physiological cause of eclampsia or the immediate post-seizure recovery.
Choice B rationale
An internal fetal heart monitor is an invasive procedure requiring the rupture of membranes and insertion of a fetal spiral electrode. This is not the priority action following a seizure. Post-seizure priority is maternal stabilization, ensuring a patent airway, and preventing further injury. External fetal monitoring is the standard first-line approach to assess fetal well-being.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate toxicity, not a treatment for seizures. Administering calcium gluconate would be inappropriate unless magnesium toxicity (e.g., respiratory depression) is suspected. The primary treatment for eclamptic seizures is magnesium sulfate, which works by depressing the central nervous system and blocking neuromuscular conduction.
Choice D rationale
Placing the client on her side is the priority action following a seizure. This position prevents aspiration of secretions, promotes venous return to the heart, and improves placental perfusion. This is a critical safety measure to protect both the mother and the fetus from further harm and is part of standard post-ictal care. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up into the chest through the diaphragm's esophageal hiatus. This displacement disrupts the lower esophageal sphincter's function, causing gastric acid to reflux into the esophagus and resulting in heartburn.
Choice B rationale
Abdominal cramping is typically associated with conditions affecting the intestines, such as irritable bowel syndrome, inflammatory bowel disease, or bowel obstruction. It is not a direct symptom of a sliding hiatal hernia, which primarily affects the stomach and esophagus.
Choice C rationale
Breathlessness or dyspnea can be a symptom of a very large hiatal hernia that compresses the lungs. However, for a standard sliding hiatal hernia, it is not a primary or expected finding. The most common manifestation is related to acid reflux.
Choice D rationale
Constipation is a condition of the large intestine and is characterized by infrequent bowel movements. It is not directly caused by a sliding hiatal hernia, as the hernia’s primary impact is on the stomach and esophagus, causing upper gastrointestinal symptoms. *.
Correct Answer is C
Explanation
Choice A rationale
The shoulder harness straps should be positioned at or below the infant's shoulders when using a rear-facing car seat. This placement ensures that the crash forces are distributed across the strongest parts of the body and prevents the baby from sliding up out of the straps during an impact.
Choice B rationale
The retainer clip, or chest clip, should be placed at the level of the armpits, across the sternum. This position ensures that the shoulder straps remain securely on the shoulders and prevents the baby from being ejected from the harness in the event of a collision. Placing it on the abdomen can cause serious injury.
Choice C rationale
A 45-degree angle in a rear-facing car seat is a crucial safety measure. This reclined position ensures that the infant's airway remains open and unobstructed. It prevents the head from slumping forward, which could lead to positional asphyxiation, especially in newborns who lack strong neck control.
Choice D rationale
Current safety recommendations advise keeping a child rear-facing for as long as possible, until they reach the maximum height or weight limits of their car seat, which is typically well beyond one year of age. Turning the seat forward-facing at 1 year is no longer considered the safest practice. *.
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