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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.
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