A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?
Place the client in a Trendelenburg position.
Assist the client to void.
Administer oxygen to the client via face mask at 10 L/min.
Give calcium gluconate to the client.
The Correct Answer is C
Choice A rationale:
Placing the client in a Trendelenburg position (head down and feet up) is not recommended after a convulsion in a pregnant client. It could potentially compromise blood flow to the brain and fetus. The priority after a convulsion is to ensure the client's airway and oxygenation.
Choice B rationale:
Assisting the client to void might be necessary during the course of care but is not the immediate action needed after a convulsion. The priority is to address airway and oxygenation needs.
Choice C rationale:
Administering oxygen to the client via face mask at 10 L/min is the correct action after the client experiences a convulsion. Eclampsia is a severe complication of preeclampsia, characterized by seizures. Providing oxygen ensures adequate oxygenation to the brain and vital organs during and after the convulsion.
Choice D rationale:
Giving calcium gluconate is not the appropriate action for eclampsia. Calcium gluconate is used to treat hyperkalemia and calcium channel blocker overdose. It does not address the underlying issue of eclampsia or prevent further convulsions. The immediate focus should be on managing the convulsions and ensuring the client's safety and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”
Choice A rationale:
The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.
Choice B rationale:
An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.
Choice C rationale:
Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.
Choice D rationale:
Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.
Correct Answer is C
Explanation
Choice A rationale:
Placing the client in a Trendelenburg position (head down and feet up) is not recommended after a convulsion in a pregnant client. It could potentially compromise blood flow to the brain and fetus. The priority after a convulsion is to ensure the client's airway and oxygenation.
Choice B rationale:
Assisting the client to void might be necessary during the course of care but is not the immediate action needed after a convulsion. The priority is to address airway and oxygenation needs.
Choice C rationale:
Administering oxygen to the client via face mask at 10 L/min is the correct action after the client experiences a convulsion. Eclampsia is a severe complication of preeclampsia, characterized by seizures. Providing oxygen ensures adequate oxygenation to the brain and vital organs during and after the convulsion.
Choice D rationale:
Giving calcium gluconate is not the appropriate action for eclampsia. Calcium gluconate is used to treat hyperkalemia and calcium channel blocker overdose. It does not address the underlying issue of eclampsia or prevent further convulsions. The immediate focus should be on managing the convulsions and ensuring the client's safety and well-being.
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