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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The statement is correct because chickenpox is highly contagious, and visiting someone with active chickenpox can put the pregnant individual at risk of contracting the infection. The recommendation is to avoid contact with individuals who have chickenpox, especially during pregnancy. The correct approach is to stay away from the infected person until they are no longer contagious (which is usually after all the sores have crusted over and dried up).
Choice B reason:
The statement Is incorrect because taking antibiotics for a viral infection is not appropriate, as antibiotics are only effective against bacterial infections, not viruses. Using antibiotics inappropriately can lead to antibiotic resistance and other potential side effects. Viral infections are generally managed with supportive care.
Choice C reason:
The statement is incorrect because handwashing is an essential infection prevention measure, but washing hands for 10 seconds with hot water may not be sufficient to remove germs effectively. The recommended duration for handwashing is at least 20 seconds with soap and water.
Choice D reason:
The statement is incorrect because cleaning a cat's litter box during pregnancy is not recommended due to the potential risk of exposure to the parasite Toxoplasma gondii, which is found in cat faeces. Toxoplasmosis can cause serious health issues in the developing foetus. It is best for pregnant individuals to avoid cleaning the litter box and have someone else do it or wear gloves and wash hands thoroughly afterward if no one else can do it.
Correct Answer is D
Explanation
Choice A reason:
Urine specific gravity should not be reported by the nurse. While urine specific gravity is an important indicator of hydration status and kidney function, the provided information does not suggest any abnormalities in urinary output or signs of kidney issues. It is not the most critical finding to report in this scenario.
Choice B reason:
Prealbumin should not be reported by the nurse. Prealbumin is a protein used to assess nutritional status, but its significance in this situation is not apparent from the provided data. It may be relevant in other contexts, such as assessing malnutrition, but it does not directly address the current findings.
Choice C reason:
Temperature should not be reported by the nurse. The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. While temperature is an important vital sign, it is not relevant to the findings presented in this scenario.
Choice D reason
The nurse should report the "hypoactive bowel sounds upon auscultation" to the provider. Hypoactive bowel sounds can be a sign of gastrointestinal (GI) motility issues, which may indicate a potential problem with the client's digestive system. It could be due to various causes such as bowel obstruction, inflammation, or other GI disorders. Reporting this finding to the provider is essential so that appropriate assessments and interventions can be taken to address the client's condition.
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