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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is **d. The newborn is beginning to cough**.

Choice A rationale:

An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.

Choice B rationale:

A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.

Choice C rationale:

A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.

Choice D rationale:

The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.

A. Cataracts B. Hearing loss. C. Macrosomia D. Urinary tract infection (UTI)

Correct Answer is B

Explanation

The correct answer is choice **b. Hearing loss**.

Choice A rationale:

Cataracts are not a common finding in newborns with congenital CMV infection. Cataracts are more commonly associated with other congenital infections like rubella, toxoplasmosis, and herpes simplex virus (HSV).

Choice B rationale:

Hearing loss is one of the most common manifestations of congenital CMV infection. Up to 40-58% of infants with symptomatic congenital CMV infection develop sensorineural hearing loss, which can be unilateral or bilateral, and progressive over time.

Choice C rationale:

Macrosomia, or large birth size, is not a typical finding in congenital CMV infection. In fact, infants with symptomatic congenital CMV infection are more likely to be small for gestational age or have intrauterine growth restriction.

Choice D rationale:

Urinary tract infection (UTI) is not a common presentation of congenital CMV infection. CMV can cause inclusion bodies in the urine, but overt UTI is not a typical finding. More common manifestations include petechiae, hepatosplenomegaly, jaundice, and central nervous system involvement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?

Correct Answer is D

Explanation

A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?

Correct Answer is B

Explanation

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