Page 688 - Saunders Comprehensive Review For NCLEX-RN

lung maturity.
15. Prepare the client for delivery as prescribed.

K. Eclampsia

1. Assessment: Characterized by generalized seizures
(Box 22-6)
2. Interventions (see Priority Nursing Actions)

Priority Nursing Actions

Eclampsia Event
1. Remain with the client and call for help.
2. Ensure an open airway, turn the client on her side, and
administer oxygen by face mask at 8 to 10 L/minute.
3. Monitor fetal heart rate patterns.
4. Administer medications to control the seizures as prescribed.
5. After the seizure has ended, insert an oral airway and suction
the client’s mouth as needed.
6. Prepare for delivery of the fetus after stabilization of the client, if
warranted.
7. Document occurrence, client’s response, and outcome.

Reference

Lowdermilk et al. (2016), p. 667

XV. Incompetent Cervix
A. Description
1. Incompetent cervix refers to premature dilation of the
cervix, which occurs most often in the fourth or fifth
month of pregnancy and is associated with structural
or functional defects of the cervix.
2. Treatment involves surgical placement of a cervical
cerclage.
B. Assessment
1. Vaginal bleeding
2. Fetal membranes visible through the cervix
C. Interventions

1. Provide bed rest, hydration, and tocolysis, as
prescribed, to inhibit uterine contractions.
2. Prepare for cervical cerclage (at 10 to 14 weeks of
gestation as prescribed), in which a band of fascia or
nonabsorbable ribbon is placed around the cervix
beneath the mucosa to constrict the internal os.
3. After cervical cerclage, the client is told to refrain from
intercourse and to avoid prolonged standing and
heavy lifting.
4. The cervical cerclage is removed at 37 weeks of

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