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 B

Explanation

A. Two fingerbreadths above the umbilicus would not be a normal finding 48 hours postpartum. By this time, the uterus should be well on its way to returning to its pre-pregnancy size and position, typically about 1 to 2 fingerbreadths below the umbilicus.

B. Two fingerbreadths below the umbilicus is the expected finding 48 hours postpartum. After birth, the uterus begins to shrink (involution) and descend into the pelvic cavity. By 48 hours, the fundus is usually 1–2 fingerbreadths below the umbilicus.

C. Four fingerbreadths below the umbilicus would be more typical of a finding several days later, after the process of involution continues. This could be a sign that the uterus is shrinking at the expected rate.

D. At the level of the umbilicus is typically expected within the first 24 hours after delivery, but by 48 hours postpartum, the fundus should have descended slightly below the level of the umbilicus.

A. stepping B. Babinski C. tonic neck D. plantar grasp

Correct Answer is B

Explanation

A. Stepping reflex is elicited by holding the newborn upright with feet touching a flat surface; the baby will make stepping movements.

B. Babinski reflex is correct. This reflex is elicited by stroking the lateral sole of the foot from the heel to the ball of the foot. A positive Babinski response in newborns is dorsiflexion of the big toe and fanning of the other toes — a normal finding up to about 12 months of age.

C. Tonic neck reflex (also called the “fencing” reflex) is seen when the newborn's head is turned to one side — the arm on that side extends while the opposite arm bends.

D. Plantar grasp is elicited by pressing a finger against the sole of the foot near the toes; the newborn will respond by curling the toes downward.

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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

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