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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. To enhance the clearing of the newborn's respiratory passages is not the primary reason for putting the newborn to the breast immediately. While early skin-to-skin contact and breastfeeding are beneficial, the clearing of respiratory passages is more directly related to the initial care the baby receives (such as suctioning if necessary), not breastfeeding.
B. To aid in maturing the newborn's sucking reflex is not the main reason for immediate breastfeeding. The sucking reflex is typically well-established in most newborns by the time of birth, and breastfeeding can help reinforce it. However, the reflex is present and functional even if the baby is not immediately breastfeeding.
C. To encourage the development of maternal antibodies is important in the longer term. Breastfeeding does provide immunological benefits to the baby (like colostrum), but the immediate reason for putting the baby to the breast is more about bonding and initiating breastfeeding.
D. To facilitate maternal-infant bonding is the primary reason for encouraging early breastfeeding. Skin-to-skin contact and breastfeeding immediately after birth promote emotional bonding between the mother and baby, which is beneficial for both. It also promotes the release of oxytocin in the mother, which supports uterine involution and maternal well-being.
Correct Answer is C
Explanation
A. Advanced maternal age may increase the risk of certain pregnancy complications, but it is not specifically associated with shoulder dystocia. Other factors, such as fetal size, are more directly related to shoulder dystocia.
B. Polyhydramnios (excess amniotic fluid) can sometimes be associated with complications during labor, but it is not the primary risk factor for shoulder dystocia. The condition most often involves difficulties with the fetal position or size rather than the amount of fluid.
C. Macrosomia (a large baby, typically defined as a birth weight over 8 pounds 13 ounces or 4000g) is the primary risk factor for shoulder dystocia. Shoulder dystocia occurs when the baby’s shoulders become stuck during delivery, often due to the larger size of the baby. The baby’s shoulders may be too broad to pass through the birth canal easily, which increases the likelihood of this complication.
D. Preterm birth is not a significant risk factor for shoulder dystocia. Preterm babies are typically smaller and less likely to encounter the same birth canal obstruction issues associated with shoulder dystocia.
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