A nurse is caring for a client who has preeclampsia.
Which of the following actions is the nurse’s priority when implementing seizure precautions?
Ensure the call button is within the client’s reach
Place suction equipment at the client’s bedside
Dim the lights in the client’s room
Pad the side rails of the client’s bed
The Correct Answer is B
Choice A rationale: Ensuring the call button is within the client's reach is important for general patient safety and communication, but it is not the highest priority for seizure precautions.
Choice B rationale: Placing suction equipment at the client's bedside is crucial for managing airway secretions during a seizure. Having suction equipment readily available ensures that the client's airway can be cleared promptly, which is vital for maintaining breathing and preventing aspiration.
Choice C rationale: Dimming the lights in the client's room can help reduce stimuli that may trigger seizures, but it is not the most urgent action to take when implementing seizure precautions.
Choice D rationale: Padding the side rails of the client's bed is important to prevent injury during a seizure, but ensuring that suction equipment is available takes priority to maintain airway patency and prevent complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Exert upward pressure on the presenting part.
Choice A rationale:
Administering a tocolytic medication can help reduce uterine contractions, but it is not the immediate priority in this emergency situation. The primary goal is to relieve pressure on the umbilical cord to restore blood flow to the fetus.
Choice B rationale:
Wrapping the cord in a sterile towel moistened with warm sterile normal saline is important to prevent the cord from drying out and to maintain its temperature. However, this action does not address the immediate need to relieve pressure on the cord.
Choice C rationale:
Applying oxygen via facemask to the client can help improve maternal oxygenation, which indirectly benefits the fetus. However, it does not directly address the immediate issue of relieving pressure on the umbilical cord.
Choice D rationale:
Exerting upward pressure on the presenting part is the most critical action to take first.This maneuver helps to relieve pressure on the umbilical cord, thereby restoring blood flow and oxygen to the fetus, which is essential in this emergency situation.
Correct Answer is C
Explanation
Choice A rationale
Feeding the newborn 5 to 10 minutes per breast may not be sufficient for the baby to get all the necessary nutrients. It is generally recommended to allow the baby to feed until they naturally let go of the breast.
Choice B rationale
Expecting two to four wet diapers every 24 hours is not accurate for a breastfeeding newborn. A well-fed newborn will typically have at least six wet diapers a day.
Choice C rationale
This is the correct answer. It is generally recommended to allow the baby to feed at least every 3 hours. This ensures that the baby gets enough nutrients and helps stimulate milk production.
Choice D rationale
Offering the newborn 30 mL (1 oz) of water between feedings is not recommended. Breast milk or formula should be the primary source of hydration for a newborn.
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