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. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
For a preschooler, play is the primary mechanism for coping and learning. A pounding board allows the child to express frustration and aggression in a safe, appropriate manner. This type of play helps to relieve tension and anxiety associated with hospitalization. It provides a healthy outlet for emotions that the child may not be able to articulate verbally, which is crucial for this developmental stage.
Choice B rationale
Preschoolers have a limited understanding of complex language. Using medical terminology can be frightening and confusing to them, increasing their anxiety. Nurses should use simple, concrete language that the child can understand, such as "checking your arm" instead of "taking your blood pressure," to help them feel more secure and cooperative with care.
Choice C rationale
Preschoolers thrive on routine and predictability. Establishing a new routine can be disruptive and increase their stress and fear. The nurse should strive to maintain as much of the child's home routine as possible to provide a sense of security and normalcy. This helps them feel more in control and less overwhelmed by the hospital environment.
Choice D rationale
A preschooler may experience separation anxiety when a parent leaves the room. Performing assessments while the parent is present helps the child feel more secure and supported. The parent can also provide comfort and help distract the child, which can make procedures easier and less frightening for the child. This promotes a trusting relationship between the child, parent, and nurse.
Correct Answer is B
Explanation
Choice A rationale
Carbonated beverages contain gas that expands the stomach, increasing pressure on the lower esophageal sphincter (LES). This increased pressure can cause the LES to relax and allow gastric contents to reflux into the esophagus, exacerbating heartburn. Additionally, the acidic nature of many carbonated drinks can irritate the already inflamed esophageal lining.
Choice B rationale
Hot herbal tea can relax the esophageal muscles and soothe irritation. However, some herbal teas, like peppermint, can relax the lower esophageal sphincter, potentially worsening reflux. In contrast, chamomile or ginger tea may have a calming effect on the stomach and reduce inflammation, which can alleviate the symptoms of heartburn.
Choice C rationale
High-fat snacks, especially those consumed at bedtime, delay gastric emptying. The presence of food in the stomach for a prolonged period increases the risk of gastric reflux. Delayed emptying leads to a larger volume of stomach contents exerting pressure on the lower esophageal sphincter, making it more likely to open and allow acid to escape.
Choice D rationale
Lying down after meals increases the pressure on the lower esophageal sphincter and places the stomach contents in a position where gravity no longer helps keep them down. This postural change makes it easier for stomach acid to flow back into the esophagus, which is a primary cause of heartburn. Remaining upright for at least 30 minutes after eating is recommended. *.
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