Delegation Health Management Practice Exam

Session length

1 / 20

When a client with preeclampsia progresses to an eclamptic state, what is the initial nursing action?

check the fetal heart rate

check the maternal blood pressure

maintain an open airway

Maintaining an open airway is crucial when a client with preeclampsia progresses to an eclamptic state. Eclampsia can lead to seizures, which pose a significant risk of airway compromise due to loss of consciousness, muscle control, and possible aspiration. The immediate priority in such a scenario is ensuring that the airway remains clear to facilitate breathing and prevent potential respiratory failure.

When a seizure occurs, as seen in eclampsia, the body may become rigid, leading to the risk of the airway being obstructed. Therefore, ensuring an open airway allows for effective ventilation and decreases the likelihood of hypoxia, which can adversely affect both the mother and the fetus. Following the establishment of an open airway, the nurse can proceed with additional assessments and interventions, such as monitoring vital signs or administering medications as needed for seizure management and stabilization of the patient's condition.

administer oxygen to the mother by face mask

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