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 A
Explanation
Rationale:
A. "I will change my baby's diaper at least every 4 hours.": Frequent diaper changes help keep the circumcision site clean and dry, reducing the risk of infection and irritation from urine or stool. Keeping the area free from moisture allows proper healing and minimizes discomfort for the newborn. This reflects correct home care following a circumcision.
B. "I will wash the penis with soap and warm water until the circumcision has healed.": Using soap on the circumcision site can cause irritation and delay healing. The area should be gently cleansed with warm water only, allowing the natural healing process to occur without additional chemical irritation from soaps or wipes containing alcohol or fragrances.
C. "I will apply topical lidocaine following each diaper change.": Topical anesthetics such as lidocaine are not recommended for routine circumcision care because they may cause toxicity or be absorbed unpredictably in newborns. Pain is managed through comfort measures such as swaddling, breastfeeding, or using petroleum jelly, not through anesthetic application.
D. "I will apply an ice pack to my baby's penis twice daily to decrease swelling.": Applying ice to a newborn’s circumcision site is unsafe and can cause tissue injury due to extreme temperature sensitivity. Mild swelling is expected and resolves naturally; the recommended care involves gentle cleansing and protecting the site with petroleum jelly not cold therapy.
Correct Answer is ["A","C","D","E","F"]
Explanation
Rationale:
A. Respiratory rate: The client’s respiratory rate decreased from 20/min to 18/min, indicating improved cardiopulmonary function and reduced physiological stress, which reflects overall improvement in health status.
B. Pain level: The client’s pain level remains at 0/10 both at baseline and follow-up, showing no change. Pain was not a concern initially, so this does not indicate improvement.
C. Blood pressure: Blood pressure decreased from 164/92 mm Hg to 138/84 mm Hg, demonstrating better hypertension management through lifestyle modifications and/or medications, indicating cardiovascular improvement.
D. LDL: LDL cholesterol improved significantly from 220 mg/dL to 90 mg/dL, reflecting effective hyperlipidemia management and reduced risk for cardiovascular disease.
E. Weight: The client’s weight decreased from 88.6 kg to 83.2 kg, reducing BMI from 30.5 to 28.7. This weight loss indicates successful lifestyle modifications and improvement in overall metabolic health.
F. Hemoglobin A1c: HbA1c decreased from 7% to 6%, showing improved long-term glycemic control and reduced risk for diabetes-related complications, reflecting an overall improvement in metabolic health.
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