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The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)

Explaining procedures.

Treating nausea.

Ensuring side rails are padded.

Assisting with breast pumping.

Evaluating blood pressure frequently.

Evaluating for headache.

Assessing deep tendon reflexes.

Minimizing visitors.

Answer and Explanation

Correct Answer : C,E,G,H

Choice A rationale

Explaining procedures is important for patient understanding and consent, but it does not directly stabilize the client's condition during an eclamptic seizure.

Choice B rationale

Treating nausea can provide symptomatic relief but does not address the primary concerns of airway protection, seizure control, and hemodynamic stability in eclamptic patients.

Choice C rationale

Ensuring side rails are padded prevents injury during seizures by providing a protective barrier, reducing the risk of trauma from uncontrolled movements.

Choice D rationale

Assisting with breast pumping does not directly impact the stabilization of an eclamptic patient. The priority is managing seizures and ensuring patient safety.

Choice E rationale

Evaluating blood pressure frequently allows for early detection of hypertension or hypotension, guiding appropriate interventions to maintain hemodynamic stability and prevent complications.

Choice F rationale

Evaluating for headache is important for assessing potential complications of eclampsia, such as intracranial hypertension, but does not directly stabilize the patient during an acute seizure.

Choice G rationale

Assessing deep tendon reflexes helps monitor neurological status and the effectiveness of magnesium sulfate therapy, guiding further treatment decisions to prevent complications.

Choice H rationale

Minimizing visitors reduces environmental stimuli, which can help lower stress levels and prevent triggering additional seizures, contributing to the patient's stabilization.

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Correct Answer is A

Explanation

Choice A rationale

Erythromycin ointment is effective for preventing ophthalmia neonatorum, a severe eye infection caused by Neisseria gonorrhoeae. It reduces the risk of blindness by inhibiting bacterial growth in the newborn's eyes.

Choice B rationale

Neomycin is not effective against Neisseria gonorrhoeae and is not recommended for preventing ophthalmia neonatorum. It is typically used for skin infections and lacks efficacy in this scenario.

Choice C rationale

Tetracaine is a topical anesthetic used for numbing the eyes. It does not possess antibacterial properties required to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.

Choice D rationale

Latanoprost is a prostaglandin analog used to treat glaucoma by reducing intraocular pressure. It does not have antibacterial properties to prevent ophthalmia neonatorum in newborns.

A. Ask a nurse with more experience to validate the costal angle finding. B. Examine the client for signs of tissue anoxia, such as pallor. C. Ask the healthcare provider to evaluate the client’s respiratory status. D. Record the respiratory finding in the client’s record as normal.

Correct Answer is D

Explanation

Choice A rationale

Asking another nurse to validate the costal angle finding is unnecessary, as the increased costal angle is a common physiological change during pregnancy due to the expanding uterus.

Choice B rationale

Examining for tissue anoxia, such as pallor, is not relevant in this scenario, as the nasal stuffiness and nosebleeds are likely due to increased blood volume and hormonal changes in pregnancy.

Choice C rationale

Requesting the healthcare provider to evaluate the client's respiratory status is unwarranted, as the described symptoms are typical physiological adaptations during pregnancy and not indicative of respiratory pathology.

Choice D rationale

Documenting the respiratory finding as normal is appropriate, as the increased chest circumference, thoracic breathing, elevated diaphragm, and increased costal angle are expected physiological changes during pregnancy.

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The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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