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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Unconjugation of bilirubin is the process where bilirubin, initially produced in a water-insoluble form (unconjugated or indirect bilirubin), is not yet processed by the liver. This form cannot be easily excreted by the body.

Choice B rationale

Albumin binding refers to the transport of unconjugated bilirubin in the bloodstream. Because unconjugated bilirubin is fat-soluble and not easily dissolved in water, it binds to albumin, a protein in the blood, which allows it to be transported to the liver.

Choice C rationale

The enterohepatic circuit describes the circulation of bile acids from the liver to the small intestine, where they aid in fat digestion and absorption, and then back to the liver. Bilirubin is a byproduct of heme breakdown and is processed separately in the liver before excretion in bile.

Choice D rationale

Conjugation of bilirubin is the process that occurs in the liver where the enzyme uridine diphosphoglucuronate glucuronosyltransferase (UGT) attaches glucuronic acid molecules to unconjugated bilirubin. This process transforms the fat-soluble unconjugated bilirubin into a water-soluble form called conjugated (or direct) bilirubin, which can then be excreted in bile into the intestines.

A. Absent early deceleration of fetal heart rate. B. Fetal heart rate is 140/min. C. Contraction frequency of 2 to 3 minutes apart. D. Contraction durations of 95 to 100 seconds.

Correct Answer is D

Explanation

Choice A rationale

Absent early decelerations of the fetal heart rate are generally considered a reassuring sign. Early decelerations are a gradual decrease and return of the fetal heart rate associated with uterine contractions, thought to be caused by fetal head compression. Their absence does not typically warrant immediate reporting.

Choice B rationale

A fetal heart rate of 140 beats per minute falls within the normal range for a term fetus, which is typically between 110 and 160 beats per minute. This finding is reassuring and does not require immediate reporting to the provider.

Choice C rationale

Contraction frequency of 2 to 3 minutes apart indicates that the labor is progressing. While the overall pattern of contractions needs to be evaluated in conjunction with other factors like duration and intensity, a frequency within this range is not necessarily a concerning finding that requires immediate reporting on its own.

Choice D rationale

Contraction durations of 95 to 100 seconds are considered prolonged. Normal contraction duration in the active phase of labor typically ranges from 45 to 60 seconds. Prolonged contractions can reduce uterine blood flow and potentially lead to fetal hypoxia, making this a concerning finding that should be promptly reported to the provider for further evaluation.

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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:

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Naxlex Comprehensive Predictor Exams

The student nurse learns that the process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as:

Correct Answer is D

Explanation

A charge nurse is teaching a group of staff nurses about fetal monitoring during labor.Which of the following findings should the charge nurse instruct the staff members to report to the provider?

Correct Answer is D

Explanation

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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: