A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure.
Which of the following actions should the nurse take following the seizure.

Choice A rationale

A color-coded wristband, such as yellow, serves as a visual cue to all healthcare staff that a client has an increased risk of falling. This system promotes a universal understanding of the client's needs, allowing all members of the care team to implement appropriate fall prevention measures proactively and consistently, such as providing assistance with ambulation or frequent rounding.

Choice B rationale

The use of physical restraints, such as a restraint around the waist, is a last resort and requires a provider's order. It is not considered a primary fall prevention strategy. Restraints can increase a client's risk of injury and are associated with negative outcomes, including agitation, skin breakdown, and loss of muscle mass. Fall prevention strategies focus on proactive, non-restrictive interventions.

Choice C rationale

Storing personal items in a bathroom, especially on a high shelf, creates a significant fall hazard. The client may overreach or stand on a stool to retrieve items, increasing their risk of losing balance. To prevent falls, all personal items should be kept within easy reach of the client, such as on the bedside table, to minimize unnecessary movement.

Choice D rationale

While keeping some light on is helpful, having overhead lights on at all times can cause glare and create shadows that distort depth perception. This can make it difficult for a client with vision impairments to see potential obstacles. A low-level nightlight is a safer alternative for nighttime visibility, as it minimizes glare and helps maintain a normal sleep-wake cycle. *.

Choice A rationale

This location, the second intercostal space at the right sternal border, corresponds to the aortic valve area. Auscultation here allows the nurse to assess the sounds produced by the aortic valve, which are distinct from the mitral valve sounds. These sounds are generated as blood is ejected from the left ventricle into the aorta during systole.

Choice B rationale

The second intercostal space at the left sternal border is the correct anatomical location for auscultating the pulmonic valve. The pulmonic valve separates the right ventricle from the pulmonary artery, and listening here allows the nurse to assess the sounds of blood flow into the pulmonary circulation.

Choice C rationale

The fifth intercostal space at the left midclavicular line is the point of maximal impulse (PMI), also known as the apical pulse, which is the anatomical location for the mitral valve. This is the optimal site for auscultating the S1 and S2 heart sounds, as well as any murmurs or abnormal sounds associated with the mitral valve's function.

Choice D rationale

This location, the fourth intercostal space at the left sternal border, is the anatomical location for the tricuspid valve. Auscultation in this area allows the nurse to assess the sounds generated by the tricuspid valve, which regulates blood flow between the right atrium and the right ventricle. *.