A woman with preeclampsia has a seizure. What is the nurse's highest priority during a seizure?

To stay with the client and call for help

To suction the mouth to prevent aspiration

To administer oxygen by mask

To insert an oral airway

Answer and Explanation

The Correct Answer is A

Choice A reason: To stay with the client and call for help is the highest priority during a seizure, because it ensures the safety of the client and the fetus, and allows the nurse to monitor the vital signs and fetal heart rate. The nurse should also protect the client from injury and turn the client to the side to prevent aspiration.

Choice B reason: To suction the mouth to prevent aspiration is not the highest priority during a seizure, because it can cause more harm than good. Suctioning can stimulate the gag reflex and increase the risk of vomiting and aspiration. It can also injure the oral mucosa and trigger another seizure.

Choice C reason: To administer oxygen by mask is not the highest priority during a seizure, because it may not be effective or necessary. Oxygen administration can be difficult or impossible during a seizure, and it may not improve the oxygen saturation or fetal outcome. Oxygen should only be given if hypoxia is confirmed by pulse oximetry or arterial blood gas analysis.

Choice D reason: To insert an oral airway is not the highest priority during a seizure, because it can be dangerous and contraindicated. Inserting an oral airway can damage the teeth and tongue, and increase the risk of vomiting and aspiration. It can also provoke another seizure or laryngospasm. An oral airway should only be used if the client is unconscious and has no gag reflex.

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Free Nursing Study Resources

Correct Answer is ["117"]

Explanation

The correct answer is 117 mL/hr.

To calculate the IV rate, the nurse should use the following formula:

IV rate (mL/hr) = (Volume to be infused (mL) / Time of infusion (hr)) x Drop factor (gtt/mL)

In this case, the volume to be infused is 350 mL, the time of infusion is 3 hr, and the drop factor is 1 gtt/mL (assuming the IV pump is calibrated in mL/hr). Therefore, the formula becomes:

IV rate (mL/hr) = (350 mL / 3 hr) x 1 gtt/mL

IV rate (mL/hr) = 116.67 mL/hr

The nurse should round the answer to the nearest whole number, which is 117 mL/hr.

A. Increased risk of anemia B. Hyperinsulinemia C. Increased blood viscosity D. Brachial plexus injury

Correct Answer is B

Explanation

Choice A reason: Increased risk of anemia is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn regardless of the maternal diabetes status or the fetal size. Anemia can cause pallor, tachycardia, and poor feeding, but not respiratory distress.

Choice B reason: Hyperinsulinemia is a likely cause of respiratory distress in a term macrosomic newborn, as it results from the fetal exposure to high maternal glucose levels and the subsequent overproduction of insulin. Hyperinsulinemia can impair the synthesis of surfactant, which is a substance that prevents the alveoli from collapsing and facilitates gas exchange. Hyperinsulinemia can also cause hypoglycemia, which can affect the respiratory center and cause apnea.

Choice C reason: Increased blood viscosity is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn with polycythemia, which is an abnormally high number of red blood cells. Polycythemia can cause cyanosis, jaundice, and thrombosis, but not respiratory distress.

Choice D reason: Brachial plexus injury is not a likely cause of respiratory distress in a term macrosomic newborn, as it affects the nerves that supply the arm and hand, not the lungs. Brachial plexus injury can occur due to the excessive traction or stretching of the shoulder during delivery, and can cause weakness, paralysis, or sensory loss in the affected arm.

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A woman with preeclampsia has a seizure. What is the nurse's highest priority during a seizure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number)

Correct Answer is ["117"]

Explanation

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

Correct Answer is B

Explanation

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