The client has experienced an eclamptic seizure.
Which of the following interventions by the nurse will help stabilize the client? Select all that apply.
Minimizing visitors.
Ensuring side rails are padded.
Assessing deep tendon reflexes.
Explaining procedures.
Evaluating for headache.
Treating nausea.
Evaluating blood pressure frequently.
Assisting with breast pumping.
Evaluating for breast pumping.
Correct Answer : A,B,C,D,E,F,G
Choice A rationale
Minimizing visitors reduces external stimuli that can exacerbate central nervous system irritability. An eclamptic seizure is a manifestation of severe preeclampsia, where cerebral vasospasm and endothelial dysfunction lead to neuronal hyperexcitability. A calm environment lowers sympathetic nervous system activation, reducing the risk of further seizure activity and promoting a stable state.
Choice B rationale
Padding side rails is a crucial safety measure to prevent physical injury during a seizure. Eclamptic seizures are characterized by tonic-clonic movements, which can cause the client to strike their limbs or head against the bed frame. Protecting the client from trauma is the highest priority during and immediately following a seizure event.
Choice C rationale
Assessing deep tendon reflexes (DTRs) evaluates the effectiveness of magnesium sulfate therapy, a common treatment for preventing and managing eclamptic seizures. Magnesium sulfate is a central nervous system depressant that can cause hypermagnesemia if administered excessively, leading to decreased or absent DTRs. The normal range for DTRs is +2.
Choice D rationale
Explaining procedures to the client, even if they appear unresponsive, helps orient them and reduce anxiety upon regaining consciousness. The period following a seizure can be disorienting and frightening. Providing a clear, calm explanation of events and planned care promotes psychological safety and reduces the client's stress response, which can otherwise increase blood pressure.
Choice E rationale
A severe headache is a common symptom of preeclampsia and can indicate worsening cerebral edema or impending seizure activity. Evaluating for headache helps in assessing the client's neurological status and the effectiveness of treatment. Persistent or new onset headaches can be a sign of increased intracranial pressure and require immediate attention to prevent further complications.
Choice F rationale
Nausea is a common symptom of preeclampsia and can be a side effect of magnesium sulfate therapy. Treating nausea is important for client comfort and to prevent vomiting, which increases intra-abdominal and intracranial pressure. This rise in pressure can further strain the cardiovascular system and potentially trigger a seizure.
Choice G rationale
Frequent evaluation of blood pressure is essential for monitoring the severity of preeclampsia and the effectiveness of antihypertensive therapy. Eclampsia is defined by the occurrence of seizures in a woman with preeclampsia, which is characterized by hypertension (blood pressure > 140/90 mm Hg). Close monitoring guides timely intervention to prevent further cerebrovascular events.
Choice H rationale
Assisting with breast pumping is not a priority intervention during the acute stabilization phase following an eclamptic seizure. The immediate focus is on maternal stabilization, seizure prevention, and management of hypertension and other complications. Breast pumping is a supportive care measure for lactation and is addressed once the client is medically stable.
Choice I rationale
Evaluating for breast pumping is not a priority intervention for stabilizing a client after an eclamptic seizure. The primary nursing responsibilities are focused on monitoring maternal vital signs, assessing neurological status, and ensuring a safe environment. Evaluation of lactation is not relevant to the immediate life-threatening condition of eclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A decrease of 0.8 g/dL in hemoglobin over two days is a significant change, not a normal fluctuation. Normal daily fluctuations are typically less than 0.5 g/dL. This magnitude of change indicates a pathological process, such as blood loss or hemodilution, which requires further investigation to determine the underlying cause.
Choice B rationale
An improvement in fluid status, such as a decrease in hypervolemia, would typically lead to an increase in hemoglobin concentration due to a reduction in the diluting effect of excess plasma volume. A decrease in hemoglobin, as observed here, suggests either blood loss or worsening fluid retention, which dilutes the red blood cell count.
Choice C rationale
While a decrease in hemoglobin can be a sign of hemorrhage, it does not, in itself, directly indicate an increased risk for future hemorrhage. It indicates that blood loss has likely already occurred or that there is an underlying issue causing the decrease. The decrease is a result of a process, not a risk factor for a future event.
Choice D rationale
The decrease in hemoglobin from 11.2 g/dL to 10.4 g/dL over a short period indicates a worsening anemic state. Anemia is a condition characterized by a deficit of red blood cells or hemoglobin. This change suggests that the underlying cause, whether it is blood loss or a physiological process, is worsening and requires intervention.
Correct Answer is B
Explanation
Choice A rationale
Allowing a child to choose an injection site may lead to an inappropriate or unsafe location. The ventrogluteal and vastus lateralis muscles are the preferred sites for intramuscular injections in children, selected based on the child's age, muscle development, and the volume of medication. Allowing a child to select an unsafe site could risk nerve or vascular injury.
Choice B rationale
Topical anesthetics, such as lidocaine/prilocaine cream, are effective in reducing the perception of pain associated with injections. They work by blocking sodium channels in neuronal membranes, preventing the propagation of pain signals to the central nervous system. Applying the cream ten minutes before the procedure allows for adequate time for the anesthetic effect to take place.
Choice C rationale
The ventrogluteal site is the preferred site for intramuscular injections in children over seven months old. The nurse should ask the child to lie on their side with the upper knee bent to a 45-degree angle. This position ensures relaxation of the gluteal muscles and allows for accurate landmarking of the greater trochanter, anterior superior iliac spine, and iliac crest, minimizing the risk of sciatic nerve injury.
Choice D rationale
Subcutaneous sites are not typically used for vitamin B12 injections. Subcutaneous injections are given into the fatty tissue below the dermis and are best for small volumes of non-irritating, water-soluble medications, such as insulin. Vitamin B12 is typically administered via the intramuscular route to ensure proper absorption into the muscle tissue.
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