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":"C","dropdown-group-2":"B"}
Explanation
The condition that poses the greatest risk to the newborn is meconium aspiration syndrome due to amniotic fluid.
Rationale for correct answers
Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid, leading to airway obstruction, chemical pneumonitis, and surfactant dysfunction. The presence of dark brown-greenish amniotic fluid, along with mild respiratory distress (nasal flaring, increased respiratory rate of 60/min), raises concern for MAS. Close monitoring for worsening respiratory symptoms is essential.
Amniotic fluid contamination with meconium increases the risk of lung inflammation and infection. The newborn’s vigorous condition suggests mild aspiration, but continuous observation is needed.
Rationale for incorrect Response 1 options
- Jaundice: While term newborns may develop physiological jaundice, there are no indications of hyperbilirubinemia or hemolysis in this case.
- Hypoglycemia: No jitteriness or poor feeding, and birth weight is within normal range; hypoglycemia more commonly affects preterm or low birth weight infants.
- Cold stress: The newborn is under a radiant warmer, and temperature is within normal range (36.5°C).
Rationale for incorrect Response 2 options
- Birth weight: No signs of growth restriction or macrosomia-associated complications.
- Acrocyanosis: Normal in newborns due to immature circulation, not an indicator of respiratory compromise.
- Apgar scores: Strong Apgar scores (8 and 9) suggest good adaptation to extrauterine life.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Upon reviewing the client’s medical record, the nurse determines that the client is at risk for developing choriocarcinoma and thyrotoxicosis.
Rationale for correct answers
Choriocarcinoma is a malignant form of gestational trophoblastic disease (GTD) that arises from a molar pregnancy, as evidenced by grape-like vesicles seen on ultrasound and excessively elevated beta-hCG (normal in pregnancy: up to 100,000 mIU/mL by late first trimester). This condition can lead to metastases if not diagnosed and treated promptly.
Thyrotoxicosis occurs due to excess beta-hCG, which stimulates thyroid hormone production. This is supported by the slightly elevated free T4 levels, a common feature of molar pregnancy-related hyperthyroidism.
Rationale for incorrect Response 1 options
- Preterm labor: The client is at 20 weeks with no contractions noted, and cervical changes are not reported.
- Placenta previa: Characterized by painless bright red bleeding later in pregnancy; this client has dark brown discharge consistent with molar pregnancy.
- Cardiac arrhythmia: No evidence of electrolyte abnormalities or arrhythmogenic conditions such as hyperkalemia.
Rationale for incorrect Response 2 options
- Preeclampsia: Normal blood pressure (≥140/90 mm Hg would be concerning); no proteinuria.
- Urinary tract infection: No leukocytes, nitrites, or dysuria reported.
- Hypoglycemia: Normal serum glucose levels; vomiting history does not indicate hypoglycemia.
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