An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
A client who is at 33 weeks of gestation and has severe gestational hypertension
A client who is at 16 weeks of gestation and has a hydatidiform mole
A client who is at 28 weeks of gestation and is experiencing vaginal bleeding
A client who is at 36 weeks of gestation and has a positive group B streptococcal culture
The Correct Answer is A
A. Correct. The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a life-threatening complication that involves seizures.
B. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures.
C. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures.
D. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Goal – oriented is the correct answer. Obsessive-compulsive personality disorder (OCPD) is a personality disorder characterized by a pattern of preoccupation with orderliness, perfectionism, and control. Individuals with OCPD tend to be highly organized, detail-oriented, and focused on achieving their goals. They often set strict standards for themselves and others and are driven by a strong need for perfection in all aspects of their lives.
Choice B reason
Provocative behaviour is not a characteristic commonly associated with obsessive-compulsive personality disorder (OCPD). In fact, individuals with OCPD tend to be more reserved, cautious, and serious in their interactions with others.
Choice C reason:
Lack of empathy While individuals with OCPD may struggle with interpersonal relationships due to their rigid standards and expectations, they typically do not lack empathy. They might find it challenging to understand and relate to emotions or perspectives that do not align with their own, but this is different from a complete lack of empathy, which is more commonly seen in certain other personality disorders.
Choice D reason.
Lability refers to emotional instability or rapid and extreme shifts in emotions. This is not a typical feature of obsessive-compulsive personality disorder (OCPD). Individuals with OCPD tend to be emotionally restrained and might have difficulty expressing emotions, rather than experiencing emotional lability.
Correct Answer is B, A, D, C
Explanation
B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.
A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.
D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.
C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.
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