When developing a teaching plan for a client at 8 weeks gestation, which instruction has the highest priority?

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.

Choice A rationale

While supervised competition can be beneficial, it may also lead to feelings of inadequacy or failure if the child does not perform well, especially in a child with prolonged illness. This could negatively impact the child's developing sense of industry versus inferiority. The focus should be on building confidence through personal mastery rather than comparison with others.

Choice B rationale

Setting goals beyond a child's abilities can be counterproductive and lead to frustration and a sense of failure. According to Erikson's stage of industry versus inferiority, children at this age need to experience success and accomplishment to build a positive self-concept and a sense of competence. Unattainable goals can foster a feeling of inferiority.

Choice C rationale

Erikson's stage of industry versus inferiority, characteristic of school-age children, focuses on developing a sense of competence and mastery. Engaging the child in achievable tasks that result in a tangible sense of accomplishment, such as completing a puzzle or a small craft project, reinforces their ability to produce and succeed, thereby promoting their sense of industry.

Choice D rationale

Targeting a child's areas of weakness can lead to feelings of inadequacy and inferiority, especially in a child who has experienced setbacks from a prolonged illness. The focus should be on building upon existing strengths and fostering a sense of accomplishment in tasks where the child can succeed, thereby building self-esteem and a sense of industry.