A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?
Monitor blood pressure pulse, and respirations every 4 hour
Keep an airway at the bedside
Allow liberal family visitation
Assess temperature every hour
The Correct Answer is B
A. Monitor blood pressure, pulse, and respirations every 4 hours: Monitoring vital signs is important, especially in a client with eclampsia. However, the frequency of monitoring may need to be increased, particularly if the client's condition is unstable.
B. Keep an airway at the bedside: This is a crucial intervention. Eclampsia can lead to seizures, and having airway management equipment readily available is essential to ensure the client's safety during and after a seizure.
C. Allow liberal family visitation: While family support is important, the priority in eclampsia management is the safety and well-being of the client. Family visitation should be allowed, but it may need to be balanced with the need for a controlled and safe environment.
D. Assess temperature every hour: While monitoring temperature is a part of routine care, it may not be the highest priority in the context of eclampsia. Monitoring for signs of imminent seizure activity and maintaining a safe environment take precedence.
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Related Questions
Correct Answer is B
Explanation
A. Bleeding tendencies:
Bleeding tendencies are not typically a priority immediately after birth unless there is a specific indication. Newborns are not at immediate risk for bleeding unless there are underlying conditions.
B. Heat loss:
Heat loss is a significant concern for newborns. Maintaining an adequate temperature is crucial to prevent hypothermia, which can lead to complications.
C. Hypoglycemia:
While monitoring blood glucose is important in the newborn, it may not be the most immediate concern within the first minutes after delivery. Stabilizing the newborn's temperature and initiating breathing are usually higher priorities.
D. Fluid balance:
Fluid balance is essential, but the initial focus is often on establishing respirations and maintaining temperature. Fluids may be administered as needed based on the clinical assessment.
Correct Answer is A
Explanation
The diaphragm must be refitted after childbirth:
This statement is correct. After childbirth, especially vaginal delivery, there can be changes in the size and tone of the vagina. Therefore, it's important to be refitted for a diaphragm after giving birth.
The most effective form of contraception is a diaphragm:
This statement is not accurate. While the diaphragm is a reversible and user-controlled method, its effectiveness can vary. It requires correct and consistent use to be effective.
The diaphragm should be inserted 2 to 4 hours before intercourse:
This statement is partially correct. The diaphragm should be inserted no more than 2 hours before intercourse and should be left in place for at least 6 hours after intercourse.
Vaseline lubricant can be used when inserting the diaphragm:
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