A nurse is caring for a pregnant client with preeclampsia.
The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the nurse's first action is to:
Clean and maintain an open airway.
Administer oxygen by face mask.
Assess the blood pressure and fetal heart rate.
Administer magnesium sulfate intravenously.
The Correct Answer is A
Choice A rationale
Maintaining a patent airway is the immediate priority in the event of a seizure associated with eclampsia. During a seizure, the client's respiratory muscles may become compromised, leading to airway obstruction and hypoxemia, which can be detrimental to both the mother and the fetus. Ensuring a clear airway allows for adequate oxygenation.
Choice B rationale
While administering oxygen is important in managing eclampsia to address potential hypoxemia, establishing and maintaining a clear airway takes precedence. Without a patent airway, supplemental oxygen delivery will be ineffective. Oxygen administration typically follows ensuring airway patency.
Choice C rationale
Assessing blood pressure and fetal heart rate is crucial in monitoring the progression of preeclampsia and eclampsia, but it is not the immediate first action during an eclamptic seizure. The immediate concern is the client's airway and preventing injury during the seizure. Monitoring follows stabilization of the airway.
Choice D rationale
Magnesium sulfate is the medication of choice to prevent and treat eclamptic seizures. However, during an active seizure, the immediate priority is to ensure the client's safety and airway. Magnesium sulfate administration would follow the initial steps of airway management and seizure precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should monitor the client’s temperature due to the risk of chorioamnionitis.
Rationale for correct answers
Temperature monitoring is crucial for detecting chorioamnionitis, an infection of the amniotic sac, which is a major risk following preterm premature rupture of membranes (PPROM). PPROM increases susceptibility to ascending bacterial infection, leading to inflammation. Fever (>38°C or 100.4°F) is a primary diagnostic criterion.
Chorioamnionitis presents with maternal fever, fetal tachycardia (>160/min), uterine tenderness, and foul-smelling amniotic fluid. The client's normal temperature now (36.7°C) requires ongoing monitoring, as infection could develop rapidly.
Rationale for incorrect Response 1 options
- Magnesium levels: Magnesium sulfate is used for seizure prophylaxis in eclampsia or for neuroprotection in preterm labor. This client has no signs of either condition.
- Fundal height: Measurement assesses fetal growth and amniotic fluid levels; it is not a direct indicator of infection risk.
- Clotting factors: No evidence of coagulopathy or bleeding abnormalities; coagulation profile is normal.
Rationale for incorrect Response 2 options
- Concealed hemorrhage: No signs of placental abruption (painful bleeding, rigid abdomen). Normal hemoglobin (12.0 g/dL) supports this.
- Seizures: No hypertensive crisis or neurological symptoms suggestive of eclampsia.
- Disseminated intravascular coagulation (DIC): No abnormal coagulation markers or evidence of excessive bleeding.
Take-home points
• PPROM increases the risk of chorioamnionitis, a serious intrauterine infection. • Fever monitoring is essential, as maternal fever is an early indicator of infection. • Antibiotics are given prophylactically to reduce chorioamnionitis risk in PPROM. • Differentiation from placental abruption, eclampsia, and DIC is based on clinical and laboratory findings.
Correct Answer is A
Explanation
Choice A rationale
Completely saturating a perineal pad within 15 minutes indicates excessive postpartum bleeding, which is most commonly caused by uterine atony (failure of the uterus to contract effectively after delivery). Massaging the fundus stimulates uterine muscles to contract, helping to compress blood vessels at the placental site and control bleeding. This is the priority intervention to prevent further blood loss and potential hemorrhage.
Choice B rationale
Assessing vital signs is important to evaluate the extent of blood loss and the woman's hemodynamic stability. However, the immediate priority is to address the cause of the excessive bleeding by promoting uterine contraction. Vital sign assessment should follow fundal massage.
Choice C rationale
Calling the primary health care provider is necessary to report the excessive bleeding and implement further management if fundal massage is not effective. However, the nurse's immediate action should be to address the likely cause of the bleeding through fundal massage.
Choice D rationale
Initiating an intravenous (IV) infusion of Ringer's lactate solution may be necessary to restore fluid volume if significant blood loss has occurred or continues. However, the immediate priority is to stop the bleeding by promoting uterine contraction through fundal massage. IV fluids are a subsequent intervention to support hemodynamic stability.
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