A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.
She is not currently convulsing.

What intervention should the nurse plan to include in this client’s nursing care plan?

Monitor blood pressure, pulse, and respirations every 4 hours.

Keep an airway at the bedside.

Allow liberal family visitation.

Assess temperature every hour.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.

Choice B rationale

Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.

Choice C rationale

Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.

Choice D rationale

Assessing temperature every hour is not specifically related to the care of a client with eclampsia.

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Correct Answer is C

Explanation

Choice A rationale

While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.

Choice B rationale

Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.

Choice C rationale

Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.

Choice D rationale

While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.

A. Monitor the variability of the fetal heart rate. B. Assess the level of pain sensation. C. Check the maternal blood pressure. D. Determine the station of the presenting part.

Correct Answer is C

Explanation

Choice A rationale

While monitoring the variability of the fetal heart rate is important during labor, it is not the most crucial assessment after administering epidural anesthesia15.

Choice B rationale

Assessing the level of pain sensation is important to ensure the effectiveness of the epidural anesthesia. However, it is not the most crucial assessment15.

Choice C rationale

Checking the maternal blood pressure is the most crucial assessment after administering epidural anesthesia15. Epidural anesthesia can cause a drop in blood pressure, which can lead to complications for both the mother and the baby.

Choice D rationale

Determining the station of the presenting part is important during labor, but it is not the most crucial assessment after administering epidural anesthesia15.

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A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.She is not currently convulsing.What intervention should the nurse plan to include in this client’s nursing care plan?

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Naxlex Comprehensive Predictor Exams

A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.What action should the nurse take?

Correct Answer is C

Explanation

What is the most crucial assessment for the nurse to perform after administering epidural anesthesia to a patient who is at 40 weeks gestation?

Correct Answer is C

Explanation

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A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.
She is not currently convulsing.

What intervention should the nurse plan to include in this client’s nursing care plan?