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 C

Explanation

Choice A rationale

Limiting the newborn's intake of milk is contraindicated in the treatment of hyperbilirubinemia. Adequate hydration and frequent feedings are essential to promote bilirubin excretion through stool and urine. Decreased intake can exacerbate dehydration and worsen jaundice. Normal feeding frequency for newborns is typically every 2-3 hours.

Choice B rationale

Feeding the newborn every six hours is not an appropriate intervention for a jaundiced infant receiving phototherapy. Frequent feedings, typically every 2-3 hours, are necessary to promote bilirubin excretion. Prolonged intervals between feedings can lead to dehydration and hinder the effectiveness of phototherapy.

Choice C rationale

Turning the infant every two hours is a crucial nursing intervention during phototherapy. This ensures that all body surfaces are exposed to the ultraviolet light, maximizing the breakdown of bilirubin in the skin. Consistent exposure of all areas helps to lower bilirubin levels more effectively.

Choice D rationale

Applying an oil-based lotion to the newborn's skin during phototherapy is contraindicated. Oil-based lotions can create a barrier on the skin, reducing the penetration and effectiveness of the ultraviolet light. Only water-based lotions, if necessary, should be used sparingly and with caution, as some may absorb UV light.

Correct Answer is ["7"]

Explanation

Step 1: Heart rate of 110/min scores 2 points (normal heart rate >100).

Step 2: Slow weak cry scores 1 point (good strong cry scores 2, no cry scores 0).

Step 3: Some flexion of extremities scores 1 point (active movement scores 2, limp scores 0).

Step 4: Grimace in response to suctioning scores 1 point (coughing or sneezing scores 2, no response scores 0).

Step 5: Body pink, blue extremities scores 1 point (completely pink scores 2, completely blue or pale scores 0).

Step 6: Total Apgar score is the sum of the scores from each category: 2 + 1 + 1 + 1 + 2 = 7. Final calculated answer: 7.

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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 newborn is jaundiced and receiving phototherapy via ultraviolet bank lights.An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

Correct Answer is C

Explanation

Correct Answer is ["7"]

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: