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 A

Explanation

Choice A rationale

Following a dilation and curettage (D&C) for a spontaneous miscarriage, the uterus needs time to heal. Resuming vaginal intercourse after approximately 2 weeks allows for some initial healing of the uterine lining and helps reduce the risk of infection. Healthcare providers typically advise waiting until bleeding has significantly decreased and discomfort has subsided.

Choice B rationale

While adequate nutrition is important for overall recovery after a miscarriage, there is no specific recommendation to increase the intake of zinc-rich foods in particular. A balanced diet supporting tissue repair is generally advised.

Choice C rationale

Aspirin is a salicylate and has antiplatelet properties. It is generally not recommended for managing cramps after a D&C due to the increased risk of bleeding. Acetaminophen or ibuprofen are typically preferred for pain relief.

Choice D rationale

Following a D&C for a spontaneous miscarriage, the products of conception have been removed from the uterus. While some vaginal bleeding is expected as the uterus heals, it should not contain identifiable fetal or placental tissue. Persistent passage of such tissue could indicate an incomplete evacuation or other complications requiring medical attention. .

A. I will avoid sexual intercourse until the bleeding has stopped, and for two weeks following the last evidence of bleeding. B. I will continue with my normal life after discharge. C. I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad. D. I will watch for the evidence of the passage of tissue.

Correct Answer is B

Explanation

Choice A rationale

Avoiding sexual intercourse is recommended in the presence of threatened abortion to prevent further uterine irritation and potential disruption of the pregnancy. Pelvic rest helps to minimize the risk of increased bleeding or complications.

Choice B rationale

Continuing with normal life after discharge is an inappropriate statement. With a threatened abortion, the client needs to understand the importance of rest and avoiding strenuous activities that could potentially exacerbate bleeding or lead to further complications. Activities that increase intra-abdominal pressure or cause physical strain should be limited.

Choice C rationale

Counting perineal pads and noting the amount and color of blood is an important instruction for monitoring the extent of bleeding. This information helps the healthcare provider assess the progression or resolution of the threatened abortion and identify any signs of increased bleeding or passage of tissue.

Choice D rationale

Watching for the evidence of the passage of tissue is crucial as it could indicate a progressing miscarriage. The client should be instructed on how to collect any passed tissue for examination by the healthcare provider to confirm the outcome of the pregnancy. .

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage.Which of the following should be included in the teaching?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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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: