A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure.

Which action should the nurse take first?

Administer oxygen via face mask

Turn the client to the side

Insert an oral airway

Give a loading dose of magnesium sulfate

Answer and Explanation

The Correct Answer is B

Turn the client to the side. This is because turning the client to the side will prevent aspiration of secretions or vomitus and maintain a patent airway during a seizure.

This is the most important and immediate action to take for a client with eclampsia who is having a tonic-clonic seizure.

Choice A is wrong because administering oxygen via face mask is not the first priority and may not be feasible during a seizure. Oxygen therapy may be indicated after the seizure to improve oxygenation and fetal well-being.

Choice C is wrong because inserting an oral airway is contraindicated during a seizure as it may cause injury to the oral mucosa or trigger a gag reflex. An oral airway may be used after the seizure if the client is unconscious and has a compromised airway.

Choice D is wrong because giving a loading dose of magnesium sulfate is not the first action to take, although it is an important intervention to prevent further seizures and lower blood pressure in eclampsia. Magnesium sulfate should be administered intravenously after securing the airway and ensuring adequate ventilation.

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Correct Answer is C

Explanation

Headache unrelieved by analgesics.This is because headache is a common symptom of HELLP syndrome, a rare pregnancy complication that can cause high blood pressure, seizures, stroke or liver rupture.HELLP syndrome is a type of preeclampsia and has similar symptoms.

Choice A is wrong because breast engorgement is a normal postpartum condition that occurs when the breasts are full of milk and become swollen and tender.

It is not related to HELLP syndrome.

Choice B is wrong because lochia rubra for 3 days postpartum is a normal finding that indicates the shedding of the uterine lining after delivery.

It is not related to HELLP syndrome.

Choice D is wrong because perineal discomfort is a common postpartum discomfort that results from the stretching and tearing of the perineal tissues during vaginal delivery.

It is not related to HELLP syndrome.

Normal ranges for blood pressure are less than 120/80 mmHg, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT.

A. “You can stop taking your blood pressure medication now that you have delivered your baby.” B. “You should avoid breastfeeding your baby until your blood pressure is normal.” C. “You should report any headache or visual changes to your doctor immediately.” D. “You should limit your fluid intake to prevent fluid overload.”

Correct Answer is C

Explanation

The nurse should instruct the client to report any headache or visual changes to the doctor immediately, as these are signs of worsening preeclampsia that can lead to serious complications such as stroke, eclampsia, or HELLP syndrome.Preeclampsia can persist or even begin after delivery, most often within 48 hours, so the client should monitor her blood pressure and symptoms until they resolve.

Choice A is wrong because the client should not stop taking her blood pressure medication without consulting her doctor.Blood pressure medication helps lower the blood pressure and protects the organs from damage.The blood pressure usually returns to normal within several days to weeks after delivery, but some clients may need medication for longer.

Choice B is wrong because the client should not avoid breastfeeding her baby unless there is a medical reason to do so.Breastfeeding has many benefits for both the mother and the baby, and does not affect the blood pressure or the preeclampsia.

Choice D is wrong because the client should not limit her fluid intake to prevent fluid overload.Fluid overload is not a common complication of preeclampsia, and limiting fluids can cause dehydration and affect the milk supply for breastfeeding.

The client should drink enough fluids to stay hydrated and follow a balanced diet.

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A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?

Correct Answer is C

Explanation

A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning to administer hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following actions should the nurse take before giving the medication? (Select all that apply.)

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate. Which assessment finding would indicate that the client is experiencing magnesium toxicity?

A nurse is providing discharge teaching to a client who had pre-eclampsia and delivered a healthy newborn. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following assessments is the most important for the nurse to perform?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who has eclampsia. Which of the following outcomes indicates that the therapy is successful?

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation. The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?

A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia. Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure.

Which action should the nurse take first?