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
B.
Keep an airway at the bedside
C.
Allow liberal family visitation
D.
Assess temperature every hour
The correct answer and Explanation is :
Correct Answer: B. Keep an airway at the bedside.
In a client with eclampsia, the risk of seizures is high even if they are not currently convulsing. Eclampsia is characterized by seizures during pregnancy, often preceded by severe preeclampsia (hypertension, proteinuria, and edema). While this client is not currently convulsing, the priority is to prevent complications if a seizure does occur.
Having an airway at the bedside is a critical safety measure. Eclampsia-induced seizures can compromise airway patency due to loss of muscle control or aspiration. Keeping an airway ready ensures immediate intervention if the client experiences a seizure. This aligns with the overall goals of care, which include preventing injury, maintaining oxygenation, and managing the complications associated with seizures.
Monitoring vital signs such as blood pressure (A) is important but not as immediately crucial as being prepared for a potential seizure, which could lead to airway obstruction or aspiration. Blood pressure monitoring is typically more frequent, such as every 15 minutes, in severe cases like eclampsia, rather than every 4 hours, making this option less appropriate for immediate safety concerns.
While family support can be helpful (C), liberal visitation may not always be advisable in critical situations like eclampsia due to the need for a calm and controlled environment. Excessive family presence might increase stimuli, potentially triggering seizures.
Temperature monitoring (D) is essential in many cases of infection or other concerns, but in this context, monitoring for fever is not the priority. Managing and preventing seizures and their associated risks should take precedence.
Thus, keeping an airway at the bedside (B) is the most immediate and vital intervention for this eclampsia client to ensure safety and rapid response in case of seizure activity.