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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?

A.

Palpate the uterus for contractions

B.

Administer oxygen 10 L/min via nonrebreather mask.

C.

Observe for post convulsion incontinence.

D.

Provide a quiet environment.

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationale:

  • Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
  • High parity: Multiparity increases the risk of uterine atony due to repeated stretching and decreased tone of the uterine muscles. This predisposes the postpartum client to poor uterine contraction and increased risk of hemorrhage.
  • Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
  • Prolonged rupture of membranes: Extended rupture of membranes (>18 hours) significantly increases the risk of intrauterine or postpartum infection, including endometritis, due to ascending bacteria from the vaginal canal. This can lead to fever, leukocytosis, and foul-smelling lochia.

Correct Answer is D

Explanation

Rationale:

A. Contraction intensity increased by ambulation: True labor contractions typically intensify with walking or activity, as the uterus works to dilate and efface the cervix. If contractions strengthen with movement, it suggests active labor rather than false labor.

B. Presence of bloody show: Bloody show indicates cervical changes with effacement and dilation, which are signs of true labor. Its presence helps differentiate true labor from false labor.

C. Slow change in dilation and effacement: True labor is characterized by progressive cervical change. Slow or minimal change in dilation and effacement is more consistent with false labor, but the primary hallmark is the nature of contractions.

D. Intermittent, painless contractions: False labor (Braxton Hicks contractions) is usually irregular, intermittent, and painless or minimally uncomfortable. They do not cause consistent cervical change and often subside with rest or position changes, making this a key distinguishing feature.

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