A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

Place a pillow under the client's head.

Gently restrain the client's arms.

Administer a muscle relaxant.

Insert a tongue blade.

Answer and Explanation

The Correct Answer is A

A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.

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Correct Answer is C

Explanation

A. Use the arms to pick up heavy items. Lifting heavy objects using only the arms increases strain on the back, worsening pain. Pregnant clients should bend at the knees and lift with their legs while keeping the back straight to reduce stress on the lumbar region.
B. Raise chairs to keep knees lower than hips. Sitting with knees lower than the hips can worsen lumbar lordosis, increasing back discomfort. Instead, knees should be at or slightly above hip level to maintain spinal alignment and reduce strain on the lower back.
C. Perform pelvic rocking exercises several times per day. Pelvic rocking strengthens and stretches lower back muscles, improving flexibility and reducing discomfort. This exercise helps alleviate strain from the growing uterus and supports better posture, decreasing back pain.
D. Sit in a hot tub for 30 min every evening. Prolonged exposure to high temperatures, such as in a hot tub, can cause maternal hyperthermia, increasing the risk of fetal neural tube defects. Warm baths are a safer option to relieve muscle tension without harmful effects.

A. Place a pulse oximeter on the client's finger. B. Administer oxygen to the client. C. Check the client's pulse rate. D. Establish a patent airway for the client.

Correct Answer is D

Explanation

A. Place a pulse oximeter on the client's finger. While assessing oxygen saturation is important, it is not the priority in this situation. The client is cyanotic with a respiratory rate of 8/min and shallow respirations, indicating severe respiratory compromise. Immediate intervention is needed before assessing oxygen saturation.
B. Administer oxygen to the client. Providing oxygen is appropriate, but it will not be effective if the client's airway is obstructed or if their respirations are inadequate. Oxygen delivery is only useful when there is a patent airway and effective ventilation.
C. Check the client's pulse rate. Assessing circulation is important, but the priority in this situation is ensuring an open airway to allow for adequate oxygenation. The client's respiratory status suggests that they may not be effectively exchanging oxygen, which must be addressed immediately.
D. Establish a patent airway for the client. The priority action is to ensure a patent airway, as compromised respirations can lead to respiratory failure and cardiac arrest. Airway management, such as repositioning the head, using airway adjuncts, or preparing for assisted ventilation, takes precedence over other interventions to ensure oxygen delivery.

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A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

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