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. Ferning is a test to detect ferning patterns in amniotic fluid under a microscope. A positive result indicates the presence of amniotic fluid but does not suggest infection.

B. Yellow-green fluid may suggest meconium-stained amniotic fluid, which is often associated with fetal distress, but it does not directly indicate infection. However, it can increase the risk of infection if the meconium is aspirated by the baby.

C. Foul odor is a key sign that infection may be present, particularly in the case of chorioamnionitis, an infection of the fetal membranes. A foul odor in the amniotic fluid suggests the presence of bacteria and should raise concern for infection, requiring prompt intervention.

D. Blue color on Nitrazine testing indicates that the amniotic fluid is alkaline, which is expected and normal, as amniotic fluid typically has a pH of 7-7.5. This test is used to confirm the rupture of membranes, not infection.

A. two fingerbreadths above the umbilicus B. two fingerbreadths below the umbilicus C. at the level of the umbilicus D. four fingerbreadths below the umbilicus

Correct Answer is C

Explanation

A. Two fingerbreadths above the umbilicus would be abnormal and may indicate uterine distension due to retained placental fragments or a full bladder, especially this long after delivery.

B. Two fingerbreadths below the umbilicus is typically expected 24 hours or more after delivery, not at 12 hours postpartum.

C. At the level of the umbilicus is normal and expected at about 12 hours postpartum. After delivery, the uterus rises slightly and is generally found at or near the umbilicus before it begins to descend (involute) by about 1 fingerbreadth per day.

D. Four fingerbreadths below the umbilicus would be expected several days postpartum, not within the first 12 hours.

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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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Correct Answer is C

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