Maternity Nursing: Antepartum Q 10
A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the nurse’s first action is to:
A. Administer magnesium sulfate intravenously
B. Assess the blood pressure and fetal heart rate.
C. Clean and maintain an open airway.
D. Administer oxygen by face mask.
Correct Answer: C. Clean and maintain an open airway.
The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.
Option A: In this case, the doctor may prescribe magnesium sulfate as well as medications to help reduce blood pressure. Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia. It can also help prolong a pregnancy for up to two days.
Option B: Preeclampsia is when the blood pressure, or the force of blood against the walls of the arteries, becomes high enough to damage the arteries and other blood vessels. Damage to the arteries may restrict blood flow. It can produce swelling in the blood vessels in the brain and to the growing baby. If this abnormal blood flow through vessels interferes with the brain’s ability to function, seizures may occur.
Option D: The initial treatment for eclampsia includes maintaining oxygen delivery to both mother and fetus, minimizing the risk of aspiration, treating the seizure, and controlling hypertension.