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 C
Explanation
Choice A rationale
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, typically occurring in the first trimester. While amniocentesis can cause some discomfort, it is not a known risk factor for hyperemesis.
Choice B rationale
Proteinuria is the presence of protein in the urine, which can be a sign of preeclampsia, a condition that can occur later in pregnancy. Amniocentesis, usually performed in the second trimester, is not directly linked to causing proteinuria.
Choice C rationale
Amniocentesis is an invasive procedure that involves inserting a needle through the abdominal wall and uterus to withdraw amniotic fluid. This procedure carries a risk of bleeding or hemorrhage from the insertion site or within the uterus. Therefore, observing for signs of hemorrhage is a crucial nursing intervention post-amniocentesis.
Choice D rationale
Hypoxia is a condition of insufficient oxygen supply to the tissues. While complications of amniocentesis could indirectly lead to fetal hypoxia in rare cases (e.g., placental abruption), it is not a direct and common complication to observe for in the mother. Hemorrhage is a more immediate and direct risk for the mother. .
Correct Answer is B
Explanation
Choice A rationale
A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While this requires intervention to prevent hypoglycemia, other parameters might indicate a more immediate threat to the newborn's well-being.
Choice B rationale
A temperature of 97.4°F (36.3°C) is below the normal range for a newborn (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increasing oxygen and glucose consumption, potentially leading to respiratory distress and hypoglycemia. Therefore, a low temperature requires immediate assessment and intervention to warm the newborn.
Choice C rationale
A respiratory rate of 48 breaths/minute is within the normal range for a newborn (typically 30-60 breaths/minute). While the respiratory rate should be monitored, it does not indicate an immediate critical issue in this case.
Choice D rationale
A pulse of 134 beats/minute is within the normal range for a newborn (typically 110-160 beats/minute). While the heart rate should be monitored, it does not indicate an immediate critical issue in this case. .
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