A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take.

Choice A rationale

Amnioinfusion is the infusion of saline into the amniotic cavity. It is used to treat umbilical cord compression or meconium staining, not to manage seizures. Initiating an amnioinfusion during a seizure would be an inappropriate and ineffective intervention that would not address the underlying physiological cause of eclampsia or the immediate post-seizure recovery.

Choice B rationale

An internal fetal heart monitor is an invasive procedure requiring the rupture of membranes and insertion of a fetal spiral electrode. This is not the priority action following a seizure. Post-seizure priority is maternal stabilization, ensuring a patent airway, and preventing further injury. External fetal monitoring is the standard first-line approach to assess fetal well-being.

Choice C rationale

Calcium gluconate is the antidote for magnesium sulfate toxicity, not a treatment for seizures. Administering calcium gluconate would be inappropriate unless magnesium toxicity (e.g., respiratory depression) is suspected. The primary treatment for eclamptic seizures is magnesium sulfate, which works by depressing the central nervous system and blocking neuromuscular conduction.

Choice D rationale

Placing the client on her side is the priority action following a seizure. This position prevents aspiration of secretions, promotes venous return to the heart, and improves placental perfusion. This is a critical safety measure to protect both the mother and the fetus from further harm and is part of standard post-ictal care. *.

The nurse should plan to include the following five findings in the report to the social worker, as they raise significant concern for elder maltreatment:
Findings to Include
• A. Client’s report of lack of access to bank accounts → Suggests financial exploitation, especially since the client gives income to the adult child but cannot access funds.
• D. Numerous bruises in various stages of healing → Strong indicator of physical maltreatment, possibly repeated trauma over time.
• E. Client’s report of lack of food in the house → Points to neglect, particularly in meeting basic nutritional needs.
• F. Client’s strong body odor → Suggests neglect in hygiene and personal care.
• G. Right arm fracture → A confirmed injury that, in context with other findings, may not align with a simple accidental fall.
Findings Not Prioritized for Reporting
• B. Client’s avoidance of eye contact → May reflect fear or discomfort, but is not specific enough to confirm maltreatment.
• C. Client’s report of weight loss → While potentially concerning, it wasn’t documented in the case and lacks supporting data like previous weight or timeframe.