A woman with preeclampsia has a seizure. What is the nurse's highest priority during a seizure?

To stay with the client and call for help

To suction the mouth to prevent aspiration

To administer oxygen by mask

To insert an oral airway

Answer and Explanation

The Correct Answer is A

Choice A reason: To stay with the client and call for help is the highest priority during a seizure, because it ensures the safety of the client and the fetus, and allows the nurse to monitor the vital signs and fetal heart rate. The nurse should also protect the client from injury and turn the client to the side to prevent aspiration.

Choice B reason: To suction the mouth to prevent aspiration is not the highest priority during a seizure, because it can cause more harm than good. Suctioning can stimulate the gag reflex and increase the risk of vomiting and aspiration. It can also injure the oral mucosa and trigger another seizure.

Choice C reason: To administer oxygen by mask is not the highest priority during a seizure, because it may not be effective or necessary. Oxygen administration can be difficult or impossible during a seizure, and it may not improve the oxygen saturation or fetal outcome. Oxygen should only be given if hypoxia is confirmed by pulse oximetry or arterial blood gas analysis.

Choice D reason: To insert an oral airway is not the highest priority during a seizure, because it can be dangerous and contraindicated. Inserting an oral airway can damage the teeth and tongue, and increase the risk of vomiting and aspiration. It can also provoke another seizure or laryngospasm. An oral airway should only be used if the client is unconscious and has no gag reflex.

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Correct Answer is A

Explanation

Choice A reason: Erythroblastosis fetalis is the correct answer, as it is a hemolytic disease of the newborn that occurs when the mother is Rh-negative and the newborn is Rh-positive, and the maternal antibodies cross the placenta and destroy the newborn's red blood cells, causing anemia, jaundice, and edema. Rh0 (D) immunoglobulin is an injection that prevents the formation of Rh-positive antibodies in the mother, and reduces the risk of erythroblastosis fetalis in the current or subsequent pregnancies.

Choice B reason: Hypobilirubinemia is not the correct answer, as it is a low level of bilirubin in the blood that can cause pale skin, poor feeding, or lethargy. Hypobilirubinemia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a common or serious complication in the newborn.

Choice C reason: Biliary atresia is not the correct answer, as it is a congenital defect of the bile ducts that prevents the flow of bile from the liver to the intestine, causing jaundice, dark urine, and clay-colored stools. Biliary atresia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a preventable complication in the newborn.

Choice D reason: Transient clotting difficulties is not the correct answer, as it is a bleeding disorder that occurs due to the deficiency of vitamin K, which is essential for the synthesis of clotting factors. Transient clotting difficulties is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is preventable by administering vitamin K to the newborn.

A. She is exhibiting hypertonic uterine dysfunction. B. She is experiencing a normal latent stage. C. She is experiencing precipitous labor. D. She is exhibiting hypotonic uterine dysfunction.

Correct Answer is A

Explanation

Choice A reason: She is exhibiting hypertonic uterine dysfunction, because she has frequent and painful contractions that are ineffective in dilating the cervix. Hypertonic uterine dysfunction occurs when the uterus contracts too often and too forcefully, resulting in poor oxygenation and fetal distress. The woman may need tocolytic therapy, pain relief, and hydration.

Choice B reason: She is not experiencing a normal latent stage, because her contractions are too frequent and too painful for this phase of labor. The normal latent stage is characterized by irregular and mild contractions that gradually increase in frequency and intensity, and cervical dilation from 0 to 3 cm.

Choice C reason: She is not experiencing precipitous labor, because her labor is not progressing rapidly. Precipitous labor is defined as labor that lasts less than 3 hours from the onset of contractions to the delivery of the baby. It is associated with cervical dilation of more than 5 cm per hour.

Choice D reason: She is not exhibiting hypotonic uterine dysfunction, because her contractions are not weak or infrequent. Hypotonic uterine dysfunction occurs when the uterus contracts too weakly or too rarely, resulting in prolonged labor and increased risk of infection. The woman may need oxytocin augmentation, amniotomy, or cesarean section.

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A woman with preeclampsia has a seizure. What is the nurse's highest priority during a seizure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an injection of Rh0 (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications?

Correct Answer is A

Explanation

A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and states that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor?

Correct Answer is A

Explanation

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