A nurse observes a client who is at 37 weeks of gestation and has preeclampsia with severe features having a seizure. Which of the following actions following the seizure should the nurse take first?
Palpate the uterus for contractions
Administer oxygen 10 L/min via nonrebreather mask.
Observe for post convulsion incontinence.
Provide a quiet environment.
The Correct Answer is B
Rationale:
A. Palpate the uterus for contractions: Assessing uterine activity is important after a seizure to monitor for labor or fetal compromise, but it does not address the immediate risk of maternal hypoxia following a seizure. This assessment can be performed after ensuring adequate oxygenation.
B. Administer oxygen 10 L/min via nonrebreather mask: After a seizure, the client is at risk for hypoxia due to apnea or increased oxygen demand. Administering high-flow oxygen is the priority action to restore oxygenation, support maternal and fetal perfusion, and prevent further complications.
C. Observe for post-convulsion incontinence: Monitoring for incontinence helps assess seizure severity and patient safety, but it does not immediately correct the critical issue of hypoxia. Observation is secondary to interventions that maintain airway and oxygenation.
D. Provide a quiet environment: Reducing stimuli can help prevent additional seizures or stress, but it is not the first priority after a seizure. Ensuring airway patency and oxygen delivery takes precedence over environmental modifications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Using this machine increases my risk of overdose.": PCA pumps are designed with safety features, including dose limits and lockout intervals, which reduce the risk of overdose. Understanding this helps the client recognize that PCA is a safe method for self-administered pain control when used correctly.
B. “I can get pain medication any time as long as I press the button”: The client can only receive medication according to the programmed dose and lockout interval. Pressing the button repeatedly will not override the safety mechanism, so this reflects a misunderstanding of how PCA pumps function.
C. "My partner can press my pain medication button for me if I am sleeping": PCA pumps are intended for self-administration only. Allowing someone else to press the button (a practice called “PCA by proxy”) can cause overdose and is unsafe, especially if the client is sleeping or sedated.
D. "I will receive a limited amount of pain medication when I press the button.": PCA pumps deliver a preset dose with a lockout interval to prevent overdose. This statement shows the client understands the safety mechanisms in place, indicating correct comprehension of PCA use.
Correct Answer is D
Explanation
Rationale:
A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Erythema migrans, associated with Lyme disease, is not spread through contact.
B. Droplet: Droplet precautions are for infections transmitted through large respiratory droplets, such as influenza or pertussis. Lyme disease does not spread via respiratory secretions, so droplet precautions are unnecessary.
C. Airborne: Airborne precautions apply to infections transmitted via small particles that remain suspended in the air, such as tuberculosis or measles. Lyme disease is not airborne, so this precaution is not required.
D. Standard: Standard precautions are appropriate for Lyme disease, including erythema migrans. These precautions involve routine hand hygiene, use of gloves when in contact with body fluids, and proper handling of contaminated materials, which are sufficient since the disease is transmitted via tick bites, not person-to-person.
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