For which of the following clients should a nurse implement seizure precautions on an antepartum unit?
A client who is at 28 weeks of gestation and has mitral valve stenosis.
A client who is at 32 weeks of gestation and has a positive Kleihauer-Betke test.
A client who is at 30 weeks of gestation and has cystic fibrosis.
A client who is at 36 weeks of gestation and has severe chronic hypertension.
The Correct Answer is D
Choice A reason: Mitral valve stenosis at 28 weeks increases cardiac workload, risking heart failure or arrhythmias due to increased blood volume in pregnancy. However, it does not directly cause seizures. Seizure risk is linked to neurological or hypertensive conditions, not cardiac valvular issues, which primarily affect hemodynamic stability and not seizure thresholds.
Choice B reason: A positive Kleihauer-Betke test at 32 weeks indicates fetal-maternal hemorrhage, requiring Rho(D) immune globulin to prevent isoimmunization. It does not increase seizure risk, as it affects blood compatibility, not neurological stability. Seizures are unrelated to this hematological issue, which primarily impacts future pregnancies rather than maternal neurological function.
Choice C reason: Cystic fibrosis at 30 weeks affects respiratory and pancreatic function, leading to infections or malabsorption, but not seizures. Seizure risk requires neurological or hypertensive triggers, not pulmonary or metabolic issues. The condition’s impact on maternal oxygenation does not directly alter seizure thresholds or neurological excitability in pregnancy.
Choice D reason: Severe chronic hypertension at 36 weeks increases seizure risk due to preeclampsia or eclampsia, where elevated blood pressure disrupts cerebral autoregulation, causing neuronal irritability. Seizure precautions are critical, as hypertension-induced endothelial damage and cerebral edema can trigger convulsions, threatening maternal and fetal safety, necessitating magnesium sulfate prophylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A WBC count of 11,000/mm3 is slightly elevated but normal in pregnancy due to physiological leukocytosis from increased immune activity. This supports maternal and fetal protection against infections. It does not indicate pathology requiring reporting, as it aligns with expected gestational changes in immune function, per hematological norms.
Choice B reason: Hematocrit of 37% is within the normal pregnancy range (37-47%), reflecting hemodilution from increased plasma volume. This ensures adequate placental perfusion and oxygen delivery. It does not indicate anemia or other complications requiring reporting, as it aligns with physiological adaptations in pregnancy, per hematological reference ranges.
Choice C reason: Creatinine of 0.9 mg/dL is normal (0.5-1 mg/dL) in pregnancy, reflecting increased glomerular filtration rate due to higher renal blood flow. This supports waste clearance for maternal and fetal health. It does not indicate renal dysfunction or require reporting, as it aligns with expected gestational renal physiology.
Choice D reason: Fasting blood glucose of 180 mg/dL indicates gestational diabetes, as it exceeds the normal range (74-106 mg/dL). Elevated glucose crosses the placenta, risking fetal macrosomia, hypoglycemia, or congenital anomalies. This requires immediate reporting for management to prevent adverse perinatal outcomes, per endocrinological and obstetric guidelines.
Correct Answer is C
Explanation
Choice A reason: Washing the circumcision site with soap and water 24 hours post-procedure risks disrupting the healing process. The plastic bell device remains in place for 5-7 days, and cleaning should avoid soap to prevent irritation. Healing relies on a dry environment to promote tissue repair and prevent infection.
Choice B reason: Removing the plastic bell 2 hours after circumcision is incorrect, as it is designed to remain in place for 5-7 days until the foreskin necroses and detaches. Premature removal risks bleeding and incomplete circumcision. The device ensures controlled tissue compression, supporting hemostasis and proper healing through localized necrosis.
Choice C reason: Monitoring for bleeding every 15 minutes for the first hour is critical, as circumcision carries a risk of hemorrhage due to penile vascularity. Frequent checks ensure early detection of complications, as neonatal coagulation is immature. This intervention supports hemostasis monitoring, aligning with post-surgical care to prevent significant blood loss.
Choice D reason: Removing yellow drainage on day two is inappropriate, as it may represent normal fibrinous exudate, a part of healing. Disturbing it risks infection or delayed tissue repair. The plastic bell promotes necrosis and healing, and exudate is expected unless accompanied by pus or odor, indicating infection.
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