A woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority?

fluid replacement

birth of the fetus

oxygenation

control of hypertension

Answer and Explanation

The Correct Answer is C

A. Fluid replacement is important for maintaining maternal and fetal circulation, but it is not the priority immediately following a seizure. Oxygenation and stabilizing the mother’s condition are more critical in the acute phase.

B. Birth of the fetus may become necessary if the mother’s condition worsens, but the immediate priority is stabilizing the mother and ensuring proper oxygenation to prevent further complications for both the mother and fetus.

C. Oxygenation is the priority intervention after a seizure in eclampsia. Seizures can lead to a decrease in oxygen levels, and ensuring adequate oxygenation is crucial for both the mother and fetus. The nurse should administer oxygen to support breathing and prevent hypoxia.

D. Control of hypertension is essential in managing eclampsia, but the immediate focus should be on stabilizing the mother post-seizure, which includes ensuring adequate oxygenation first. Once stabilized, antihypertensive medications can be administered as necessary.

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Correct Answer is C

Explanation

A. Lochia is the normal postpartum vaginal discharge of blood and tissue, and its duration or volume is not affected by Kegel exercises.
B. Uterine involution ,the shrinking of the uterus to its pre-pregnancy size ,is a natural physiological process and is not influenced by Kegel exercises.
C. Kegel exercises specifically target the pelvic floor muscles, which may be weakened during pregnancy and childbirth. These exercises help strengthen the muscles, support pelvic organs, and prevent issues such as urinary incontinence.
D. While improved muscle tone may eventually support healing, these exercises are not a direct method for pain relief.

A. deficient fluid volume B. risk for infection C. impaired parenting D. hypothermia

Correct Answer is D

Explanation

A. Deficient fluid volume is not the priority concern at this time. While newborns are at risk for dehydration, there are no indications in the assessment (such as dry mucous membranes or poor feeding) that would suggest deficient fluid volume as the immediate priority.

B. Risk for infection is a concern for all newborns, especially in the first hours of life. However, the information provided does not suggest signs of infection such as fever, lethargy, or abnormal skin color.

C. Impaired parenting may be a concern later on if the parents show difficulty bonding or caring for the infant. However, this is not the immediate priority based on the infant's current assessment.

D. Hypothermia is the priority. The infant’s axillary temperature of 95.8° F (35.4° C) is below the normal range for a newborn, which is typically between 97.7° F (36.5° C) and 99.5° F (37.5° C). Hypothermia in newborns can lead to complications such as respiratory distress, metabolic instability, and increased risk for infection. Immediate interventions, such as warming the infant and ensuring a warm environment, are necessary to prevent further complications.

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A woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a postpartum client how to do muscle-clenching (Kegel) exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

Correct Answer is C

Explanation

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

Correct Answer is D

Explanation

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