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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Uterine hypertonicity is not typically associated with placenta previa. Hypertonicity refers to an overly active uterus with contractions that are too strong, too long, or too close together.
Choice B rationale
Painless vaginal bleeding is a classic symptom of placenta previa. The bleeding is usually bright red and can be heavy.
Choice C rationale
Persistent headache is not a typical symptom of placenta previa. It is more commonly associated with conditions like preeclampsia.
Choice D rationale
Fetal distress is not a direct symptom of placenta previa, but it can occur if the placenta is not providing enough oxygen and nutrients to the fetus.
Correct Answer is C
Explanation
Choice A rationale
While demonstrating proper bathing of the infant is an important skill for new mothers, it is not typically a primary goal during the taking-in phase. This phase is characterized by the mother’s need to review her birth experience and begin to process her new role.
Choice B rationale
Verbalizing appropriate car seat safety is important, but it is not a primary goal during the taking-in phase. This phase is more focused on the mother’s internal processing of her birth experience.
Choice C rationale
This is the correct answer. Having adequate nutritional intake is a key goal during the taking-in phase. Good nutrition is essential for healing and recovery after childbirth, as well as for breastfeeding.
Choice D rationale
Identifying necessary family roles is an important part of adjusting to parenthood, but it is not a primary goal during the taking-in phase. This phase is more about the mother’s personal adjustment and recovery.
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