A nurse is caring for a client with HELLP syndrome who is receiving magnesium sulfate intravenously.
What is the main purpose of this medication?
To prevent seizures
To lower blood pressure
To increase urine output
To improve platelet count
The Correct Answer is C
Maintain a dark and quiet environment. This intervention helps to reduce sensory stimulation and prevent seizures in a client with eclampsia.
Choice A is wrong because monitoring fetal heart rate and uterine activity continuously is not a priority intervention for a client with eclampsia. The priority is to prevent seizures and control blood pressure.
Choice B is wrong because administering oxytocin to augment labor is contraindicated in a client with eclampsia. Oxytocin can increase blood pressure and cause uterine hyperstimulation, which can worsen the condition and endanger the mother and the fetus.
Choice D is wrong because encouraging oral fluids and a high-protein diet is not appropriate for a client with eclampsia.
The client should be kept NPO to prevent aspiration in case of a seizure. A high-protein diet can increase the risk of renal failure and hepatic dysfunction.
Choice E is wrong because assessing for signs of placental abruption is not a specific intervention for a client with eclampsia. Placental abruption can occur as a complication of eclampsia, but it is not the main focus of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Two or more accelerations of at least 15 beats/min above baseline lasting for at least 15 seconds in a 20-minute period.This indicates a reactive test, which means that the fetus is well oxygenated and not in distress.
Choice B is wrong because no accelerations or decelerations in a 20-minute period indicate a non-reactive test, which may suggest fetal hypoxia or acidosis.
Choice C is wrong because one acceleration of at least 10 beats/min above baseline lasting for at least 10 seconds in a 20-minute period is the criterion for a reactive test for gestational age less than 32 weeks, not 34 weeks.
Choice D is wrong because variable decelerations with normal variability in a 20-minute period indicate cord compression or fetal head compression, not a reactive test.
Correct Answer is A
Explanation
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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