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The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)

Explaining procedures.

Treating nausea.

Ensuring side rails are padded.

Assisting with breast pumping.

Evaluating blood pressure frequently.

Evaluating for headache.

Assessing deep tendon reflexes.

Minimizing visitors.

Answer and Explanation

Correct Answer : C,E,G,H

Choice A rationale

Explaining procedures is important for patient understanding and consent, but it does not directly stabilize the client's condition during an eclamptic seizure.

Choice B rationale

Treating nausea can provide symptomatic relief but does not address the primary concerns of airway protection, seizure control, and hemodynamic stability in eclamptic patients.

Choice C rationale

Ensuring side rails are padded prevents injury during seizures by providing a protective barrier, reducing the risk of trauma from uncontrolled movements.

Choice D rationale

Assisting with breast pumping does not directly impact the stabilization of an eclamptic patient. The priority is managing seizures and ensuring patient safety.

Choice E rationale

Evaluating blood pressure frequently allows for early detection of hypertension or hypotension, guiding appropriate interventions to maintain hemodynamic stability and prevent complications.

Choice F rationale

Evaluating for headache is important for assessing potential complications of eclampsia, such as intracranial hypertension, but does not directly stabilize the patient during an acute seizure.

Choice G rationale

Assessing deep tendon reflexes helps monitor neurological status and the effectiveness of magnesium sulfate therapy, guiding further treatment decisions to prevent complications.

Choice H rationale

Minimizing visitors reduces environmental stimuli, which can help lower stress levels and prevent triggering additional seizures, contributing to the patient's stabilization.

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Correct Answer is A

Explanation

Choice A rationale

Bradycardia (heart rate 56 beats/minute) is common postpartum due to increased stroke volume and reduced heart rate, reflecting physiological adaptation after delivery.

Choice B rationale

Saturating two perineal pads per hour is excessive and could indicate postpartum hemorrhage, requiring immediate evaluation and intervention.

Choice C rationale

A soft, spongy fundus indicates uterine atony, a serious condition requiring urgent intervention to prevent postpartum hemorrhage.

Choice D rationale

Unilateral lower leg pain could indicate deep vein thrombosis (DVT), a significant postpartum complication needing immediate medical attention.

A. Offer a pacifier dipped in glucose water. B. Give a PRN dose of liquid acetaminophen. C. Place petrolatum gauze dressings on the site. D. Wrap the infant in warm receiving blankets.

Correct Answer is C

Explanation

Choice A rationale

Glucose water may be soothing due to the sweet taste, but it does not address the immediate need to protect the circumcision site from infection and aid in healing.

Choice B rationale

Liquid acetaminophen provides pain relief, but it does not address the immediate need to protect the circumcision site. Pain management alone is not sufficient for postoperative care.

Choice C rationale

Applying petrolatum gauze dressings on the site prevents the wound from sticking to the diaper, reduces irritation, and protects against infection, promoting healing. This is a priority intervention post-circumcision.

Choice D rationale

While keeping the infant warm is important for comfort and stability, it does not directly address the need to care for the circumcision site to prevent complications and promote healing.

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The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)

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