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 {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"}}
Explanation
• Regurgitation: This could be a sign of potential worsening condition as it might indicate gastrointestinal issues, which can be a symptom of Neonatal Abstinence Syndrome (NAS).
• Transient strabismus: This is unrelated to the diagnosis. Strabismus is common in newborns and usually resolves on its own within the first few months of life.
• Mottling: This could be a sign of potential worsening condition. Mottling (a lacy pattern of dilated blood vessels under the skin) can be a sign of distress in a newborn.
• Respiratory rate 70/min: This could be a sign of potential worsening condition. A respiratory rate of 70/min is higher than the normal range (30-60 breaths per minute) for a newborn, indicating possible respiratory distress.
• Continuous high-pitched cry: This could be a sign of potential worsening condition. A high-pitched cry is a common symptom of NAS.
• Loose stools: This could be a sign of potential worsening condition. Loose stools can be a symptom of NAS.
Correct Answer is D
Explanation
Choice A rationale
An incompetent cervix is a condition that occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy. This is not typically associated with rapid labor progression.
Choice B rationale
Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance. Mild cases are treated with dietary changes, rest, and antacids. It’s not related to the speed of labor progression.
Choice C rationale
An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. It’s not related to the speed of labor progression.
Choice D rationale
Postpartum hemorrhage is the correct answer. Rapid labor progression can lead to a higher risk of postpartum hemorrhage due to uterine atony, where the uterus fails to contract after the delivery.
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