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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Thoroughly cooking meat to an internal temperature of 160°F (71°C) kills the Toxoplasma gondii parasite, thus preventing transmission. This is a recommended measure to prevent toxoplasmosis during pregnancy.

Choice B rationale

Drinking unpasteurized milk poses a risk of exposure to various pathogens, including Toxoplasma gondii, as pasteurization is a process that kills harmful microorganisms. Pregnant women should avoid unpasteurized dairy products to reduce the risk of infection. This statement indicates a need for further instruction as it suggests an unsafe practice.

Choice C rationale

Cat feces can contain oocysts of Toxoplasma gondii. Avoiding contact with materials potentially contaminated with cat feces, such as litter boxes or garden soil, is a crucial measure to prevent toxoplasmosis.

Choice D rationale

Raw meat can be contaminated with Toxoplasma gondii. Avoiding touching mucous membranes of the mouth or eyes while handling raw meat and washing hands thoroughly afterwards prevents the parasite from entering the body. This is a recommended preventive measure.

A. Deep tendon reflexes of +1. B. 3+ protein in the urine. C. Blood pressure 148/98 mm Hg. D. Pitting sacral edema.

Correct Answer is A

Explanation

Choice A rationale

Deep tendon reflexes of +1 are hypoactive reflexes, indicating decreased neurological excitability. In preeclampsia, central nervous system irritability is a key feature, often leading to hyperreflexia, which would be documented as +2, +3, or +4. Therefore, +1 reflexes are inconsistent with preeclampsia.

Choice B rationale

3+ protein in the urine indicates significant proteinuria, which is a hallmark sign of preeclampsia. The kidneys are affected in preeclampsia, leading to increased excretion of protein in the urine.

Choice C rationale

A blood pressure of 148/98 mm Hg is elevated and falls within the diagnostic criteria for preeclampsia, which is hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) that develops after 20 weeks of gestation along with proteinuria or other signs of end-organ damage.

Choice D rationale

Pitting sacral edema, or swelling in the sacral area that leaves a pit when pressed, is a common finding in preeclampsia due to fluid retention and increased capillary permeability.

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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:

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Naxlex Comprehensive Predictor Exams

A prenatal nurse is providing instructions to a group of pregnant clients regarding measures to prevent toxoplasmosis.Which statement, if made by one of the clients, indicates a need for further instructions?

Correct Answer is B

Explanation

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Correct Answer is A

Explanation

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A nurse is caring for a client who has hyperemesis gravidarum.Which of the following laboratory tests should the nurse anticipate?

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A nurse is caring for a 26-year-old female client who is at 14 weeks of gestation in the antepartum clinic. Exhibits Select the 3 findings that are unexpected.

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: