The nurse observes a new staff member caring for an eclamptic client following a seizure.
Which of the following actions by the staff member indicates an understanding of eclampsia?
Check each urine for presence of ketones.
Pad the client's bed rails and headboard.
Provide visual and auditory stimulation.
Place the bed in the high Fowler's position.
The Correct Answer is B
Choice A rationale
Checking for ketones in urine is related to metabolic conditions like diabetic ketoacidosis, not directly relevant to the immediate care of an eclamptic client.
Choice B rationale
Padding the bed rails and headboard helps prevent injury during seizures, which is crucial in managing a client with eclampsia.
Choice C rationale
Providing visual and auditory stimulation can increase the risk of further seizures in an eclamptic client. Reducing stimulation is usually recommended.
Choice D rationale
Placing the bed in the high Fowler's position is not appropriate for managing a client post-seizure. The priority is ensuring airway patency and preventing injury.
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Correct Answer is C
Explanation
Choice A rationale
A 15-year-old, G3 P0020, although young, doesn't have an increased risk of uterine rupture related to prior surgical deliveries or other known factors.
Choice B rationale
A 22-year-old, G1 P0000 with eclampsia requires close monitoring for complications related to eclampsia but not specifically for uterine rupture.
Choice C rationale
A 25-year-old, G4 P3003 with a previous cesarean section is at increased risk for uterine rupture due to the scar from the prior surgery which could weaken under the stress of labor.
Choice D rationale
A 32-year-old, G2 P0100's history of a prior fetal demise does not specifically increase the risk of uterine rupture unless accompanied by other risk factors. .
Correct Answer is B
Explanation
Choice A rationale
Labor dystocia involves prolonged labor. Her fast delivery history suggests the opposite, indicating rapid labor progress.
Choice B rationale
Rapid labor progression, frequent contractions, and previous short labors suggest she is at risk for precipitous labor, requiring immediate preparation for delivery.
Choice C rationale
Cephalopelvic disproportion indicates size mismatch between baby and pelvis, not rapid labor. Her history of quick deliveries does not align with this condition.
Choice D rationale
False labor typically involves irregular, less intense contractions. Her regular, intense contractions and labor history suggest active labor, not false labor.