Question

A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following should the nurse do upon the client's arrival?

A. Position the client in a supine position
b. Auscultate breach sounds every 4 h
c. Monitor the vital signs every 4 h
d. Admit the client to a quiet, darkened room

Answer 1

The nurse should admit the client to a quiet, darkened room. Thus option D is corerct.

Step-by-step explanation:

Admitting the client to a quiet, darkened room (d) is the most appropriate action upon the client's arrival. This scenario suggests eclampsia, a severe complication of pregnancy characterized by seizures. Placing the client in a supine position (a) might compromise her airway and is contraindicated during pregnancy. Auscultating breath sounds every 4 hours (b) and monitoring vital signs (c) at this point aren't the priority; immediate stabilization and assessment of the client's condition take precedence.

Eclampsia requires urgent attention to prevent further seizures and complications for both the mother and fetus. The priority is to ensure a safe environment to prevent injury during seizures, and a quiet, darkened room aids in seizure management by minimizing sensory stimulation. This allows for close monitoring and timely intervention if further seizures occur. Continuous monitoring of vital signs and fetal well-being will follow, but the initial focus is on stabilizing the client and preventing further seizures, which is best achieved in a quiet, controlled environment to reduce stimuli triggering another seizure. Thus option D is correct.