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 C
Explanation
Rationale:
A. Metoclopramide: Metoclopramide is an antiemetic and prokinetic agent used to treat nausea and gastroparesis. It is not classified as a controlled substance because it does not have potential for abuse or dependence.
B. Dantrolene: Dantrolene is a muscle relaxant used to treat spasticity and malignant hyperthermia. It is not a controlled substance as it has low potential for abuse or addiction.
C. Midazolam: Midazolam is a benzodiazepine used for sedation, anesthesia, and seizure management. Benzodiazepines are classified as controlled substances due to their potential for dependence, abuse, and misuse, making midazolam a controlled drug.
D. Ketorolac: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used for short-term pain management. It is not a controlled substance because it has minimal risk for abuse or dependence.
Correct Answer is A
Explanation
Rationale:
A. History of severe menorrhagia: A copper IUD can increase menstrual bleeding and cramping. Clients with a history of severe menorrhagia are at higher risk for exacerbated bleeding and anemia, making this a contraindication to IUD insertion. Alternative contraceptive methods should be considered for these clients.
B. Desire to become pregnant in 1 to 2 years: While the client’s future fertility plans may influence contraceptive choice, it is not a medical contraindication. The IUD can be removed at any time, allowing fertility to return quickly, so this does not preclude insertion.
C. Takes antiretroviral therapy for HIV: HIV infection or antiretroviral therapy is not a contraindication to IUD use. Clients with HIV can safely use intrauterine contraception, provided there are no active pelvic infections.
D. Report of unprotected sex in the past 24 hr: Recent unprotected intercourse is not a contraindication, but the nurse should assess the risk of pregnancy and consider emergency contraception if appropriate. It does not medically prevent IUD insertion.
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