A nurse is assessing a client with eclampsia who is having a seizure.
Which of the following actions should the nurse take first?
Turn the client to the side
Insert an oral airway
Administer oxygen via face mask
Document the duration of the seizure
The Correct Answer is A
Turn the client to the side. This is because turning the client to the side will prevent aspiration and maintain a patent airway during a seizure.
Some possible explanations for the other choices are:
• Choice B. Insert an oral airway. This is wrong because inserting an oral airway during a seizure can cause injury to the client’s mouth or teeth, and it can also stimulate the gag reflex and increase the risk of vomiting and aspiration.
• Choice C. Administer oxygen via face mask. This is wrong because administering oxygen via face mask during a seizure can be difficult and ineffective, as the client may not be able to breathe through the mask or may dislodge it with their movements. Oxygen can be given after the seizure has stopped, if needed.
• Choice D. Document the duration of the seizure.
This is wrong because documenting the duration of the seizure is not a priority action during a seizure. The nurse should first ensure the client’s safety and airway patency, and then document the seizure characteristics after it has ended.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The target blood pressure goal for a client with severe pre-eclampsia is less than 160/110 mmHg.
This is because lowering the blood pressure too much or too fast can compromise the placental perfusion and fetal oxygenation.
Choice A is wrong because it is the target blood pressure goal for a client with chronic hypertension or gestational hypertension without severe features.
Choice B is wrong because it is the target blood pressure goal for a client with mild pre-eclampsia.
Choice D is wrong because it is too high and can increase the risk of maternal and fetal complications such as stroke, eclampsia, placental abruption, and fetal growth restriction.
Normal blood pressure ranges are less than 120/80 mmHg for systolic and diastolic pressures respectively.
Correct Answer is A
Explanation
According to Mayo Clinic, loss of reflexes is a sign of magnesium toxicity and requires immediate intervention.
Other signs of magnesium toxicity include:
• Decreased urine output
• Difficulty breathing
• Drowsiness or confusion
• Low blood pressure
• Slow heart rate
• Weakness
Choice B is wrong because headache is not a sign of magnesium toxicity.
It may be a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
Choice C is wrong because nausea is not a sign of magnesium toxicity.
It may be a side effect of magnesium sulfate or a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
Choice D is wrong because blurred vision is not a sign of magnesium toxicity.
It may be a symptom of preeclampsia or other conditions, but it does not indicate an overdose of magnesium sulfate.
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