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. Difficulty in arousing suggests central nervous system depression, which can be a sign of magnesium toxicity. This is not a therapeutic effect and requires immediate assessment and possible discontinuation of the medication.
B. Deep tendon reflexes 2+ indicates normal neuromuscular function, which is consistent with therapeutic levels of magnesium sulfate. Loss of deep tendon reflexes is often the first sign of magnesium toxicity, so their presence at a normal level is reassuring.
C. Urinary output of 20 mL per hour is below the expected minimum (typically 30 mL/hour) and may suggest impaired renal function, which increases the risk of magnesium accumulation and toxicity.
D. Respiratory rate of 10 breaths/minute is lower than normal and may indicate respiratory depression, a serious sign of magnesium toxicity. A rate below 12 breaths/minute is concerning and not consistent with therapeutic dosing.

A. evidence that the newborn is becoming chilled. B. a good time to initiate breast-feeding. C. the period of decreased responsiveness preceding sleep. D. A sign that the infant is being overstimulated.

Correct Answer is B

Explanation

A. Evidence that the newborn is becoming chilled would typically include signs such as cool skin, mottling, or acrocyanosis ,not active behaviors like head movement and eye contact.
B. A good time to initiate breast-feeding is correct. The described behaviors ,eye contact, head movement, and tongue thrusting, are characteristic of the first period of reactivity, which occurs within the first 30 minutes after birth. During this time, the newborn is alert, responsive, and exhibits strong rooting and sucking reflexes, making it an ideal window to begin breastfeeding.
C. The period of decreased responsiveness preceding sleep typically occurs after the first period of reactivity and is marked by reduced activity and interest in feeding, not alert behaviors.
D. A sign that the infant is being overstimulated would usually involve signs like gaze aversion, hiccupping, or flailing ,not purposeful movements or eye contact.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is B

Explanation

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

Correct Answer is B

Explanation

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

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