A nurse is caring for a pregnant client with preeclampsia.
The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the nurse's first action is to:
Clean and maintain an open airway.
Administer oxygen by face mask.
Assess the blood pressure and fetal heart rate.
Administer magnesium sulfate intravenously.
The Correct Answer is A
Choice A rationale
Maintaining a patent airway is the immediate priority in the event of a seizure associated with eclampsia. During a seizure, the client's respiratory muscles may become compromised, leading to airway obstruction and hypoxemia, which can be detrimental to both the mother and the fetus. Ensuring a clear airway allows for adequate oxygenation.
Choice B rationale
While administering oxygen is important in managing eclampsia to address potential hypoxemia, establishing and maintaining a clear airway takes precedence. Without a patent airway, supplemental oxygen delivery will be ineffective. Oxygen administration typically follows ensuring airway patency.
Choice C rationale
Assessing blood pressure and fetal heart rate is crucial in monitoring the progression of preeclampsia and eclampsia, but it is not the immediate first action during an eclamptic seizure. The immediate concern is the client's airway and preventing injury during the seizure. Monitoring follows stabilization of the airway.
Choice D rationale
Magnesium sulfate is the medication of choice to prevent and treat eclamptic seizures. However, during an active seizure, the immediate priority is to ensure the client's safety and airway. Magnesium sulfate administration would follow the initial steps of airway management and seizure precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hydralazine is an antihypertensive medication used to manage hypertension, not preterm labor. Administering hydralazine would be inappropriate for a client in preterm labor unless she also has hypertension.
Choice B rationale
Preparing the client for immediate delivery based solely on a lecithin-to-sphingomyelin (L/S) ratio of 1: is premature. An L/S ratio of 2: or greater is generally indicative of fetal lung maturity. A ratio of 1: suggests lung immaturity, and interventions to promote lung maturity are indicated.
Choice C rationale
Infusing a bolus of IV fluids might be considered for hydration in preterm labor, but it does not directly address the issue of fetal lung immaturity indicated by the low L/S ratio. While hydration can help manage preterm contractions in some cases, it is not the primary intervention to improve fetal lung maturity.
Choice D rationale
Administering betamethasone, a corticosteroid, is the appropriate action for a client in preterm labor with a low L/S ratio (1:). Betamethasone crosses the placenta and stimulates the production of surfactant in the fetal lungs, accelerating lung maturity and reducing the risk of respiratory distress syndrome in the preterm infant. The typical dose is 12 mg IM, given in two doses 24 hours apart. .
Correct Answer is A
Explanation
Choice A rationale
A neonate's respiratory rate of 46 breaths per minute is within the normal range for a newborn, which is typically between 30 and 60 breaths per minute. Shallow respirations and brief periods of apnea lasting less than 20 seconds are also common in the immediate newborn period as the respiratory system adapts to extrauterine life. Therefore, continued routine monitoring is the appropriate initial action.
Choice B rationale
While apnea monitors are used for infants at high risk for apnea, such as preterm infants or those with known respiratory issues, a healthy term neonate with brief periods of apnea less than 20 seconds and a respiratory rate within the normal range does not typically require continuous electronic monitoring. This intervention would be premature given the current assessment findings.
Choice C rationale
Following a respiratory arrest protocol is indicated when a patient exhibits signs of respiratory distress or cessation of breathing. The neonate's current respiratory rate of 46 bpm, although shallow with brief pauses, does not indicate respiratory arrest. Initiating such a protocol would be an overreaction to the current assessment findings.
Choice D rationale
While it is important to keep the pediatrician informed about any significant changes in a neonate's condition, the findings described (respiratory rate of 46 bpm, shallow respirations, and apnea up to 5 seconds) are often normal in the first few hours after birth. Calling the pediatrician immediately for these findings alone is not the priority action; continued monitoring is more appropriate initially.
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