A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?
Dim the lights in the client's room.
Ensure the call button is within the client's reach.
Pad the side rails of the client's bed.
Place suction equipment at the client's bedside.
The Correct Answer is C
Choice A rationale:
Dimming the lights in the client’s room can help create a calming environment but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice B rationale:
Ensuring the call button is within the client’s reach is important for patient safety and communication, but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice C rationale:
Padding the side rails of the client’s bed is the priority when implementing seizure precautions for a client with preeclampsia. This is to protect the client from injury during a seizure.
Choice D rationale:
Placing suction equipment at the client’s bedside is important for maintaining airway patency after a seizure, but it is not the priority when implementing seizure precautions for a client with preeclampsia.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A depressed anterior fontanel is not typically caused by forceps-assisted birth. It can indicate dehydration or intracranial pressure.
Choice B rationale:
Uneven gluteal skinfolds could suggest developmental dysplasia of the hip, not a forceps injury.
Choice C rationale:
Epicanthal folds are a normal characteristic in many populations and are not related to birth injuries.
Choice D rationale:
Facial asymmetry can occur due to pressure from the forceps on the facial nerves during delivery.
Correct Answer is B
Explanation
Choice A rationale:
Asking if the partner is pressuring the client to have sex is important, but it’s not the most relevant question when a client requests birth control.
Choice B rationale:
Asking what the client knows about contraception is the most relevant question. It allows the nurse to assess the client’s knowledge and provide appropriate education.
Choice C rationale:
Asking if the client is sure their partner loves them is not relevant to the client’s request for birth control.
Choice D rationale:
Asking why the client is requesting birth control is important, but it’s not as relevant as assessing the client’s knowledge about contraception.
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