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.

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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Correct Answer is ["A","C","D"]

Explanation

Rationale:

A. Check gastric residuals every 4 hr: Monitoring gastric residual volume every 4 hours helps assess tolerance to enteral feeding and reduces the risk of aspiration. High residuals may indicate delayed gastric emptying, requiring adjustment of the feeding regimen or provider notification.

B. Check placement of the feeding tube by x-ray once daily: X-ray is the gold standard for initial confirmation of tube placement, not for routine daily checks. Ongoing verification is typically done by assessing pH of gastric aspirate and observing for signs of misplacement, making daily x-rays unnecessary and impractical.

C. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration during continuous enteral feedings. Proper positioning is a key intervention to promote safety and prevent complications such as pneumonia.

D. Change the feeding container and tubing every 24 hr: Changing the feeding container and tubing every 24 hours helps prevent bacterial contamination and infection. This is a standard infection-control measure in enteral feeding care.

E. Ensure the formula is cold before administration: Formula should be at room temperature before administration. Cold formula can cause gastrointestinal discomfort, cramping, and nausea, so heating it to room temperature improves tolerance and safety.

A. Calcium B. Potassium C. Ammonia D. Glucose

Correct Answer is C

Explanation

Rationale:

A. Calcium: While calcium is important for many bodily functions, it is not a primary indicator for monitoring hepatic encephalopathy. Calcium imbalances do not directly correlate with the severity or management of this condition.

B. Potassium: Potassium levels are important for overall electrolyte balance, but they are not specific to hepatic encephalopathy. Monitoring potassium is part of routine care but does not indicate the progression or severity of encephalopathy.

C. Ammonia: Elevated ammonia levels are a key contributor to hepatic encephalopathy. The liver normally converts ammonia to urea, and when liver function is impaired, ammonia accumulates, affecting neurological function. Monitoring ammonia helps assess severity and guide treatment interventions.

D. Glucose: While glucose monitoring is important in general care, it is not specific to hepatic encephalopathy. Hyper- or hypoglycemia may occur with liver disease but does not directly reflect the presence or progression of encephalopathy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a client who has hepatic encephalopathy. Which of the following laboratory values should the nurse monitor?

Correct Answer is C

Explanation

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