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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:

A.

Clean and maintain an open airway.

B.

Administer oxygen by face mask.

C.

Assess the blood pressure and fetal heart rate.

D.

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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Related Questions

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B,C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B,C"}}

Explanation

  • Postpartum Endometritis is the most likely concern here, considering the fever, foul-smelling lochia, uterine tenderness, and tachycardia.
  • Postpartum Hemorrhage is a possibility due to the boggy uterus and tachycardia, though her bleeding appears moderate.
  • Lactational Mastitis is unlikely since the patient has no breast tenderness or redness.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Rationales for Each Condition

Neonatal Abstinence Syndrome (NAS)

  1. Temperature: Infants experiencing NAS often have difficulty regulating body temperature due to autonomic instability. While the newborn's temperature of 36.6°C (97.9°F) is within normal range, the use of a radiant warmer suggests challenges in maintaining thermoregulation, which is characteristic of NAS.
  2. Jitteriness: Jitteriness is observed in both hypoglycemia and NAS. In NAS, it is caused by neurological excitability due to opioid withdrawal, leading to tremors and hypertonia, which improve with soothing measures such as swaddling.
  3. Skin Color: Mottling is a frequent sign in neonates experiencing opioid withdrawal due to autonomic dysregulation. The absence of cyanosis or jaundice indicates that the mottling is due to withdrawal rather than an underlying pathology.
  4. GI Assessment: Loose stools and hyperactive bowel sounds are typical signs of NAS, caused by increased gastrointestinal motility due to withdrawal from opioids.

Hypoglycemia

  1. Jitteriness: Hypoglycemia is characterized by neuromuscular instability, leading to jitteriness. However, in this case, the newborn’s blood glucose level of 45 mg/dL is within acceptable neonatal range, making NAS a more likely explanation.
  2. Temperature, Skin Color, and GI Assessment: Hypoglycemia does not typically cause mottled skin or loose stools, making these findings more consistent with NAS.

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