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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.
- B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.
- C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.
- D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.
Correct Answer is ["A","B","C","D"]
Explanation
- A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
- B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
- C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
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