A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure.
Which of the following actions should the nurse take following the seizure.
Initiate an amnioinfusion.
Apply an internal fetal heart monitor.
Administer calcium gluconate via IV bolus.
Place the client on her side.
The Correct Answer is D
Choice A rationale
Amnioinfusion is the infusion of saline into the amniotic cavity. It is used to treat umbilical cord compression or meconium staining, not to manage seizures. Initiating an amnioinfusion during a seizure would be an inappropriate and ineffective intervention that would not address the underlying physiological cause of eclampsia or the immediate post-seizure recovery.
Choice B rationale
An internal fetal heart monitor is an invasive procedure requiring the rupture of membranes and insertion of a fetal spiral electrode. This is not the priority action following a seizure. Post-seizure priority is maternal stabilization, ensuring a patent airway, and preventing further injury. External fetal monitoring is the standard first-line approach to assess fetal well-being.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate toxicity, not a treatment for seizures. Administering calcium gluconate would be inappropriate unless magnesium toxicity (e.g., respiratory depression) is suspected. The primary treatment for eclamptic seizures is magnesium sulfate, which works by depressing the central nervous system and blocking neuromuscular conduction.
Choice D rationale
Placing the client on her side is the priority action following a seizure. This position prevents aspiration of secretions, promotes venous return to the heart, and improves placental perfusion. This is a critical safety measure to protect both the mother and the fetus from further harm and is part of standard post-ictal care. *.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the rate of formula delivery would worsen hyperosmolar dehydration. A faster rate delivers more solute-rich formula to the gastrointestinal tract in a shorter time, pulling more free water from the body's vascular space into the gut lumen via osmosis. This fluid shift further depletes the body's free water, intensifying the dehydration and increasing serum osmolality.
Choice B rationale
Hyperosmolar dehydration occurs when the body's free water is drawn into the gastrointestinal tract due to a high solute concentration in the enteral formula. By adding free water to the formula, the nurse dilutes the solution, lowering its osmolarity. This action helps to balance the osmotic gradient, reducing the fluid shift and preventing further dehydration.
Choice C rationale
Switching to a lactose-free formula is indicated for clients with lactose intolerance, which causes symptoms like diarrhea and bloating, but it does not directly address hyperosmolar dehydration. Hyperosmolar dehydration is related to the overall solute load and concentration of the formula, not specifically the presence or absence of lactose.
Choice D rationale
Repositioning the NG tube is an action to ensure proper placement and prevent complications like aspiration, but it does not resolve hyperosmolar dehydration. This type of dehydration is a systemic problem related to fluid and electrolyte balance, not a local issue with the tube's position within the gastrointestinal tract. *.
Correct Answer is C
Explanation
Choice A rationale
Storing transdermal scopolamine patches in the refrigerator is incorrect. Scopolamine patches are designed to be stored at controlled room temperature, typically between 20 to 25 degrees Celsius, to maintain the integrity of the adhesive and the stability of the medication. Refrigeration can compromise the patch's adhesive properties, potentially causing it to fall off, and may also affect the rate of drug delivery.
Choice B rationale
Replacing a dislodged patch onto the same location is incorrect. The skin's absorption capabilities at the initial site may be reduced due to the previous application, leading to a diminished therapeutic effect. Applying a new or dislodged patch to a new, clean, and dry site, typically behind the ear, ensures optimal drug absorption and efficacy, which is a crucial aspect of patient education.
Choice C rationale
Applying the patch prior to traveling is correct. Transdermal scopolamine requires a significant onset time to achieve therapeutic blood levels to effectively prevent the symptoms of motion sickness. The recommendation is to apply the patch at least four hours before the anticipated travel to allow for sufficient absorption and systemic distribution of the medication to the central nervous system.
Choice D rationale
Placing the patch on the upper arm is incorrect. The recommended application site for transdermal scopolamine is the postauricular area, which is the hairless skin behind the ear. This location offers a thin epidermis and a rich capillary network, facilitating consistent and effective absorption of the medication into the systemic circulation, which is essential for its prophylactic antiemetic effect. *.
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