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

Answer and Explanation

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 lifethreatening 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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Correct Answer is D

Explanation

Choice A rationale:

Wire cutters are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Wire cutters are used for cutting wires and may be found in orthopedic or surgical trays, but they are not specifically required for thoracotomy care.

Choice B rationale:

A tracheostomy tray is not necessary for postoperative care following a thoracotomy with chest tube placement. Tracheostomy trays contain supplies for managing a tracheostomy, which is a procedure involving the creation of an opening in the neck to help with breathing. This procedure is not related to thoracotomy care.

Choice C rationale:

Montgomery straps are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Montgomery straps are used to secure dressings or bandages without adhesive tape. They are not typically used in thoracotomy care.

Choice D rationale:

A padded clamp is essential equipment for postoperative care after a thoracotomy with chest tube placement. The clamp is used to temporarily close or occlude the chest tube during transportation or when changing the drainage system. This prevents air from entering the pleural space, maintaining proper suction and preventing complications such as pneumothorax.

A. Measuring the group's work against the assigned objectives B. Noting the progress of the group toward assigned goals C. Sharing experiences as an authority figure D. Offering new and fresh ideas on an issue

Correct Answer is B

Explanation

- A. Incorrect. Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.

- B. Correct. Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.

- C. Incorrect. Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.

- D. Incorrect. Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.

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An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

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