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 C
Explanation
Choice A reason: Polyuria is not an adverse effect of epidural analgesia. Epidurals may cause urinary retention due to bladder sensation loss from nerve blockade, not increased urine output. Polyuria could reflect unrelated conditions like diabetes insipidus, but it does not align with epidural’s neurological effects on bladder function.
Choice B reason: A maternal temperature of 37.4°C (99.4°F) is within normal range and not an adverse effect of epidural analgesia. Epidurals may rarely cause fever due to immune responses, but this temperature is physiological. It does not indicate a complication requiring documentation, per obstetric monitoring standards.
Choice C reason: Hypotension is a common adverse effect of epidural analgesia, as sympathetic blockade causes vasodilation, reducing blood pressure. This can impair placental perfusion, risking fetal hypoxia. Documentation is critical to prompt interventions like fluid boluses, ensuring maternal and fetal stability, per epidural pharmacology and obstetric care protocols.
Choice D reason: A fetal heart rate of 152/min is within the normal range (110-160/min) and not an adverse effect of epidural analgesia. While epidurals may cause maternal hypotension affecting fetal perfusion, this rate indicates fetal well-being, not requiring documentation as an adverse effect, per fetal monitoring guidelines.
Correct Answer is B
Explanation
Choice A reason: Assessing for abdominal tenderness does not address uterine atony or vaginal bleeding. Tenderness may indicate other issues, like infection, but atony requires immediate uterine contraction to control hemorrhage. Fundal massage directly stimulates myometrial contraction, addressing the primary cause of bleeding, per postpartum hemorrhage management protocols.
Choice B reason: Performing a fundal massage is the priority for uterine atony, as it stimulates myometrial contractions, promoting hemostasis at the placental site. Atony causes excessive bleeding due to poor uterine tone, and massage enhances oxytocin release, constricting blood vessels to reduce hemorrhage, aligning with obstetric emergency interventions.
Choice C reason: Avoiding sterile vaginal examinations does not address uterine atony or bleeding. Examinations assess cervical or vaginal trauma but do not correct myometrial failure. Atony requires active interventions like fundal massage to restore uterine tone and control hemorrhage, making this action irrelevant to the immediate physiological need.
Choice D reason: Obtaining a Kleihauer-Betke test assesses fetal-maternal hemorrhage, relevant for Rh-negative mothers, not uterine atony. Atony causes bleeding from poor uterine contraction, not fetal blood loss. This test does not address the immediate need to control hemorrhage through myometrial stimulation, per postpartum hemorrhage management principles.
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