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 A

Explanation

Choice A rationale

Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss.

Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.

Choice B rationale

While hypoglycemia is a concern in newborns, especially those born to mothers with diabetes, it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice C rationale

Fluid balance is important in newborns, but it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice D rationale

While newborns do have immature clotting mechanisms, making them more prone to bleeding tendencies, this is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

A. Unilateral lower leg pain. B. Soft, spongy fundus. C. Pulse rate of 56 beats/minute. D. Saturating two perineal pads per hour.

Correct Answer is C

Explanation

Choice A rationale

Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.

Choice B rationale

A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.

Choice C rationale

A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.

Choice D rationale

Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.What priority issue should the nurse address to ensure the newborn’s survival?

Correct Answer is A

Explanation

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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?