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 D

Explanation

Rationale:

A. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections because it provides a large muscle mass with minimal risk of injury to nerves or blood vessels. It is not appropriate for subcutaneous injections, which require sites with adequate subcutaneous tissue rather than deep muscle.

B. Vastus lateralis: The vastus lateralis is commonly used for intramuscular injections, especially in infants and young children. For adults, it is not a typical site for subcutaneous injections due to the thicker muscle and risk of intramuscular delivery.

C. Forearm: The forearm is generally reserved for intradermal injections, such as tuberculin testing. Its limited subcutaneous tissue makes it unsuitable for subcutaneous injections intended to be absorbed slowly.

D. Upper thigh: The anterior or lateral aspect of the upper thigh provides an adequate layer of subcutaneous tissue, making it a safe and effective site for subcutaneous injections. It allows for slower absorption of medication and is easily accessible for the nurse.

A. Forearm B. Ventrogluteal C. Outer posterior aspect of upper arm D. Vastus lateralis

Correct Answer is C

Explanation

Rationale:

A. Forearm: The forearm is not a recommended site for subcutaneous injections because it has limited subcutaneous tissue and is typically reserved for intradermal injections, such as allergy testing or tuberculosis screening.

B. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections due to the large muscle mass and low risk of nerve injury. It is not suitable for subcutaneous injections, which require fatty tissue rather than muscle.

C. Outer posterior aspect of upper arm: This site contains adequate subcutaneous tissue, is easily accessible, and is commonly used for subcutaneous injections such as insulin or heparin. It allows for proper absorption and minimizes the risk of intramuscular administration.

D. Vastus lateralis: The vastus lateralis is part of the thigh and is primarily used for intramuscular injections, especially in infants or adults needing large-volume IM medications. It is not a typical site for subcutaneous injections.

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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 preparing to administer a subcutaneous injection to a client. Which of the following sites should the nurse choose?

Correct Answer is D

Explanation

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following sites should the nurse choose?

Correct Answer is C

Explanation

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