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NurseDive Free Nursing Practice Question
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?
A. Monitor blood pressure pulse, and respirations every 4 hour
Monitor blood pressure, pulse, and respirations every 4 hours: Monitoring vital signs is important, especially in a client with eclampsia. However, the frequency of monitoring may need to be increased, particularly if the client's condition is unstable.
B. Keep an airway at the bedside
Keep an airway at the bedside: This is a crucial intervention. Eclampsia can lead to seizures, and having airway management equipment readily available is essential to ensure the client's safety during and after a seizure.
C. Allow liberal family visitation
Allow liberal family visitation: While family support is important, the priority in eclampsia management is the safety and well-being of the client. Family visitation should be allowed, but it may need to be balanced with the need for a controlled and safe environment.
D. Assess temperature every hour
Assess temperature every hour: While monitoring temperature is a part of routine care, it may not be the highest priority in the context of eclampsia. Monitoring for signs of imminent seizure activity and maintaining a safe environment take precedence.
This question is an excerpt from Nurse Dive's nursing test bank - Samuel Merrit University Oaklands Hesi Maternity (Labor and Delivery) Proctored Exam. Take the full exam now
Full Explanation
A. Monitor blood pressure, pulse, and respirations every 4 hours: Monitoring vital signs is important, especially in a client with eclampsia. However, the frequency of monitoring may need to be increased, particularly if the client's condition is unstable.
B. Keep an airway at the bedside: This is a crucial intervention. Eclampsia can lead to seizures, and having airway management equipment readily available is essential to ensure the client's safety during and after a seizure.
C. Allow liberal family visitation: While family support is important, the priority in eclampsia management is the safety and well-being of the client. Family visitation should be allowed, but it may need to be balanced with the need for a controlled and safe environment.
D. Assess temperature every hour: While monitoring temperature is a part of routine care, it may not be the highest priority in the context of eclampsia. Monitoring for signs of imminent seizure activity and maintaining a safe environment take precedence.
Similar Questions
The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?
A. Cleanse the spinal injection site
Cleanse the spinal injection site:Cleansing the spinal injection site is a routine part of maintaining proper hygiene during and after the administration of spinal anesthesia. However, if the client is experiencing symptoms of a spinal headache, the priority is to prepare for potential interventions by having the necessary equipment ready rather than focusing on the site itself.
B. Apply an abdominal binder
Apply an abdominal binder:Applying an abdominal binder is not directly related to addressing a spinal headache. Abdominal binders are typically used for providing support to the abdominal muscles after childbirth or surgery. It wouldn't be the primary intervention for a spinal headache.
C. Insert an indwelling Foley catheter
Insert an indwelling Foley catheter: Inserting an indwelling Foley catheter is not a direct intervention for addressing a spinal headache. Spinal headaches are related to cerebrospinal fluid leakage and positioning. While managing the patient's overall care is important, it may not be the immediate priority in this context.
D. Place procedure equipment at bedside
Place procedure equipment at bedside:This is the most appropriate action in the context of a postpartal client exhibiting symptoms of a spinal headache. Having the necessary procedure equipment, such as materials for a blood patch, ready at the bedside ensures preparedness for potential interventions by the anesthesiologist.
Full Explanation
A. Cleanse the spinal injection site:
Cleansing the spinal injection site is a routine part of maintaining proper hygiene during and after the administration of spinal anesthesia. However, if the client is experiencing symptoms of a spinal headache, the priority is to prepare for potential interventions by having the necessary equipment ready rather than focusing on the site itself.
B. Apply an abdominal binder:
Applying an abdominal binder is not directly related to addressing a spinal headache. Abdominal binders are typically used for providing support to the abdominal muscles after childbirth or surgery. It wouldn't be the primary intervention for a spinal headache.
C. Insert an indwelling Foley catheter:
Inserting an indwelling Foley catheter is not a direct intervention for addressing a spinal headache. Spinal headaches are related to cerebrospinal fluid leakage and positioning. While managing the patient's overall care is important, it may not be the immediate priority in this context.
D. Place procedure equipment at bedside:
This is the most appropriate action in the context of a postpartal client exhibiting symptoms of a spinal headache. Having the necessary procedure equipment, such as materials for a blood patch, ready at the bedside ensures preparedness for potential interventions by the anesthesiologist.
A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
A. Estimated amount of fluid.
Estimated amount of fluid:Knowing the estimated amount of amniotic fluid can provide some information, but it may not be as crucial as other factors in this situation. The primary concern is often related to the color and odor of the amniotic fluid to assess for potential issues.
B. Color and consistency of fluid.
Color and consistency of fluid:This is a crucial piece of information. The color and consistency of amniotic fluid can provide important clues about fetal well-being and the presence of meconium, which may indicate fetal distress.
C. Time the membranes ruptured
Time the membranes ruptured: Knowing the time when the membranes ruptured is essential for assessing the duration of time since the rupture. This information helps in determining the risk of infection, which is a concern after prolonged rupture of membranes.
D. Any odor noted when membranes ruptured
Any odor noted when membranes ruptured:This is also a critical piece of information. An unpleasant odor, especially if it is foul-smelling, could be indicative of infection. Infection risk increases with prolonged rupture of membranes.
Full Explanation
A. Estimated amount of fluid:
Knowing the estimated amount of amniotic fluid can provide some information, but it may not be as crucial as other factors in this situation. The primary concern is often related to the color and odor of the amniotic fluid to assess for potential issues.
B. Color and consistency of fluid:
This is a crucial piece of information. The color and consistency of amniotic fluid can provide important clues about fetal well-being and the presence of meconium, which may indicate fetal distress.
C. Time the membranes ruptured:
Knowing the time when the membranes ruptured is essential for assessing the duration of time since the rupture. This information helps in determining the risk of infection, which is a concern after prolonged rupture of membranes.
D. Any odor noted when membranes ruptured:
This is also a critical piece of information. An unpleasant odor, especially if it is foul-smelling, could be indicative of infection. Infection risk increases with prolonged rupture of membranes.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?
A. Bleeding tendencies
Bleeding tendencies:Bleeding tendencies are not typically a priority immediately after birth unless there is a specific indication. Newborns are not at immediate risk for bleeding unless there are underlying conditions.
B. Heat loss
Heat loss:Heat loss is a significant concern for newborns. Maintaining an adequate temperature is crucial to prevent hypothermia, which can lead to complications.
C. Hypoglycemia
Hypoglycemia: While monitoring blood glucose is important in the newborn, it may not be the most immediate concern within the first minutes after delivery. Stabilizing the newborn's temperature and initiating breathing are usually higher priorities.
D. Fluid balance
Fluid balance:Fluid balance is essential, but the initial focus is often on establishing respirations and maintaining temperature. Fluids may be administered as needed based on the clinical assessment.
Full Explanation
A. Bleeding tendencies:
Bleeding tendencies are not typically a priority immediately after birth unless there is a specific indication. Newborns are not at immediate risk for bleeding unless there are underlying conditions.
B. Heat loss:
Heat loss is a significant concern for newborns. Maintaining an adequate temperature is crucial to prevent hypothermia, which can lead to complications.
C. Hypoglycemia:
While monitoring blood glucose is important in the newborn, it may not be the most immediate concern within the first minutes after delivery. Stabilizing the newborn's temperature and initiating breathing are usually higher priorities.
D. Fluid balance:
Fluid balance is essential, but the initial focus is often on establishing respirations and maintaining temperature. Fluids may be administered as needed based on the clinical assessment.