An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
A client who is at 33 weeks of gestation and has severe gestational hypertension
A client who is at 16 weeks of gestation and has a hydatidiform mole
A client who is at 28 weeks of gestation and is experiencing vaginal bleeding
A client who is at 36 weeks of gestation and has a positive group B streptococcal culture
The Correct Answer is A
A. Correct. The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a life-threatening complication that involves seizures.
B. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures.
C. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures.
D. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
"Repeat the dose if your child vomits within 1 hour after taking the medication." This statement is incorrect. If a child vomits within 1 hour after taking digoxin, the parents should not repeat the dose. The reason is that the child may have already absorbed a sufficient amount of the medication before vomiting, and an additional dose could lead to digoxin toxicity.
Choice B reason:
"You can add the medication to a half-cup of your child's favourite juice." This statement is incorrect. Adding digoxin to juice or any other food or drink is not recommended. Digoxin should be administered separately and not mixed with food or liquids to ensure accurate dosing and prevent potential interactions with other substances.
Choice C reason:
"Have your child drink a small glass of water after swallowing the medication." This statement is correct. Giving a small glass of water after administering digoxin helps ensure that the medication is fully swallowed and goes into the stomach, reducing the risk of it being retained in the mouth or throat.
Choice D reason:
"Limit your child's potassium intake while she is taking this medication." This statement is not accurate. Digoxin is often prescribed in conjunction with other heart failure medications, some of which may impact potassium levels. However, the parents should not arbitrarily limit the child's potassium intake without specific instructions from the healthcare provider. The healthcare provider will monitor the child's potassium levels and adjust the treatment plan as necessary.
Correct Answer is {"A":{"answers":"A, B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
A. Intellectual impairment
- The correct answer is ID.
- Intellectual impairment is a core feature of ID, which is characterized by significant limitations in intellectual functioning and adaptive behavior that are present before age 18.
- Intellectual impairment can sometimes be a feature of ADHD, but it's not a defining characteristic. ADHD, or Attention Deficit Hyperactivity Disorder, primarily involves difficulties with attention, hyperactivity, and impulsivity. However, some individuals with ADHD may also experience challenges with certain aspects of cognitive function, such as executive function, working memory, and processing speed. These difficulties can sometimes be mistaken for intellectual impairment, but it's important to note that ADHD itself does not necessarily indicate lower intelligence. ADHD is a neurodevelopmental disorder that affects individuals differently, and many people with ADHD have average or above-average intelligence..
B. Losing necessary things
- The correct answer is ADHD.
- Losing necessary things is a common symptom of ADHD, especially in the inattentive subtype. Children with ADHD may have difficulty organizing their belongings, remembering where they put them, or keeping track of them.
- Losing necessary things is not a specific indicator of ID, although children with ID may also have difficulties with memory and organization.
C. Impaired language skills
- The correct answer is ID.
- Impaired language skills are often associated with ID, as language development depends on cognitive abilities and social interactions. Children with ID may have delays or difficulties in acquiring, understanding, or using spoken or written language.
- Impaired language skills are not a typical feature of ADHD, although some children with ADHD may have coexisting language disorders or learning disabilities.
D. Hyperreactivity to sensory input
- The correct answer is ADHD.
- Hyperreactivity to sensory input is a possible manifestation of ADHD, especially in the hyperactive-impulsive subtype. Children with ADHD may be easily distracted by external stimuli, such as noises, lights, or movements, or may seek sensory stimulation by fidgeting, touching, or moving around.
- Hyperreactivity to sensory input is not a characteristic of ID, although some children with ID may also have sensory processing issues or autism spectrum disorder.
E. Interrupting others
- The correct answer is ADHD.
- Interrupting others is another common sign of ADHD, especially in the hyperactive-impulsive subtype. Children with ADHD may have difficulty waiting their turn, following social rules, or respecting others' boundaries. They may blurt out answers, comments, or questions without thinking or listening.
- Interrupting others is not a typical behavior of children with ID, although some children with ID may also have social skill deficits or communication problems.
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