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 {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should monitor the client’s temperature due to the risk of chorioamnionitis.
Rationale for correct answers
Temperature monitoring is crucial for detecting chorioamnionitis, an infection of the amniotic sac, which is a major risk following preterm premature rupture of membranes (PPROM). PPROM increases susceptibility to ascending bacterial infection, leading to inflammation. Fever (>38°C or 100.4°F) is a primary diagnostic criterion.
Chorioamnionitis presents with maternal fever, fetal tachycardia (>160/min), uterine tenderness, and foul-smelling amniotic fluid. The client's normal temperature now (36.7°C) requires ongoing monitoring, as infection could develop rapidly.
Rationale for incorrect Response 1 options
- Magnesium levels: Magnesium sulfate is used for seizure prophylaxis in eclampsia or for neuroprotection in preterm labor. This client has no signs of either condition.
- Fundal height: Measurement assesses fetal growth and amniotic fluid levels; it is not a direct indicator of infection risk.
- Clotting factors: No evidence of coagulopathy or bleeding abnormalities; coagulation profile is normal.
Rationale for incorrect Response 2 options
- Concealed hemorrhage: No signs of placental abruption (painful bleeding, rigid abdomen). Normal hemoglobin (12.0 g/dL) supports this.
- Seizures: No hypertensive crisis or neurological symptoms suggestive of eclampsia.
- Disseminated intravascular coagulation (DIC): No abnormal coagulation markers or evidence of excessive bleeding.
Take-home points
• PPROM increases the risk of chorioamnionitis, a serious intrauterine infection. • Fever monitoring is essential, as maternal fever is an early indicator of infection. • Antibiotics are given prophylactically to reduce chorioamnionitis risk in PPROM. • Differentiation from placental abruption, eclampsia, and DIC is based on clinical and laboratory findings.
Correct Answer is B
Explanation
Choice A rationale
Reducing fluid intake will not alleviate breast engorgement and may even be detrimental to milk production and overall maternal hydration. Engorgement is caused by increased blood flow and milk production in the breasts, not excess fluid intake.
Choice B rationale
Frequent breastfeeding, ideally every 1-2 hours, helps to remove milk from the breasts, which relieves pressure and engorgement. Regular emptying of the breasts signals the body to regulate milk production and prevents the buildup of milk that causes discomfort and can lead to complications like mastitis.
Choice C rationale
Avoiding the use of a breast pump when breasts are engorged can worsen the condition. A breast pump can be used to express milk and relieve pressure if the infant is not feeding effectively or frequently enough. Complete milk removal is key to reducing engorgement.
Choice D rationale
Skipping feedings will exacerbate breast engorgement as milk will continue to accumulate in the breasts, increasing pressure, pain, and the risk of complications. Regular milk removal is essential for managing engorgement and establishing a healthy breastfeeding pattern.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.