In planning care for the client with preeclampsia who progresses to eclampsia, what is the first action the nurse should take?

• A. Administer oxygen by face mask.
• B. Clear and maintain an open airway.
• C. Administer magnesium sulfate IV.
• D. Assess the blood pressure and fetal heart rate.

Answer: (B)

The priority in an eclamptic seizure is securing the airway. When a seizure occurs, the patient can lose airway protection, leading to aspiration and inadequate oxygen delivery. The nurse’s first action is to clear and maintain a patent airway, which includes turning the patient to a side-lying position to prevent choking, protecting the head, and suctioning as needed. Once the airway and breathing are stabilized, other measures such as administering magnesium sulfate IV to prevent further seizures and providing oxygen if indicated can be started. Monitoring blood pressure and fetal heart rate remains important, but it does not take precedence over ensuring a safe airway during an active seizure.