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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale

A Coombs positive result does not necessarily mean that the newborn will require immediate intervention. It indicates that the newborn should be monitored for potential complications such as jaundice and anemia.
Choice B rationale
While the newborn’s glucose level is within the normal range, this does not directly relate to the Coombs positive result.
Choice C rationale
A Coombs positive result may indicate Rh or ABO incompatibility, but this does not directly answer the question of what the nurse should anticipate.
Choice D rationale
This is the correct answer. A Coombs positive result indicates that the newborn should be monitored for signs of jaundice, as this could be a potential complication.

A. This test determines if your baby is at risk for developing hypoglycemia after birth B. This test will detect the presence of Rh-positive antibodies in your blood C. This test will determine the amount of amniotic fluid around the fetus D. This test assesses blood flow to the fetus and placenta using ultrasound

Correct Answer is B

Explanation

Choice A rationale
The indirect Coombs test does not determine if a baby is at risk for developing hypoglycemia after birth. It is used to screen for Rh incompatibility.
Choice B rationale
The indirect Coombs test is used to detect the presence of Rh-positive antibodies in your blood. This is particularly important in pregnancy as it can indicate a risk of Rh incompatibility.
Choice C rationale

The indirect Coombs test does not determine the amount of amniotic fluid around the fetus.
Choice D rationale
The indirect Coombs test does not assess blood flow to the fetus and placenta using ultrasound.

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A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse’s priority when implementing seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old. The newborn has a Coombs positive result and a glucose level of 50 mg/dL (40 to 60 mg/dL). What should the nurse anticipate?

Correct Answer is D

Explanation

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs test. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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A nurse is caring for a client who has preeclampsia.
Which of the following actions is the nurse’s priority when implementing seizure precautions?