A nurse observes a client who is at 37 weeks of gestation and has preeclampsia with severe features having a seizure. Which of the following actions following the seizure should the nurse take first?

Rationale:

A. The nurse should dispose of the ampule in the trash can: Glass ampules are considered sharps and must be disposed of in a designated sharps container to prevent injury and maintain safety. Throwing them in regular trash is unsafe and violates standard precautions.

B. The nurse should use the same needle to draw up and inject the client: Using the same needle can introduce glass particles or contamination into the client’s tissue. A new sterile needle should be used for injection after withdrawing the medication to ensure safety and sterility.

C. The nurse should use a filter needle to withdraw the medication: A filter needle is designed to prevent small glass shards from being drawn into the syringe when breaking the ampule. This action protects the client from injury and ensures that the medication administered is free from particulate matter.

D. The nurse should break the neck of the ampule toward their body: The ampule should always be broken away from the body to prevent injury from glass shards. Breaking it toward oneself increases the risk of cuts and contamination, making it an unsafe practice.

Rationale:

A. Use gauze to secure an arm board to the involved extremity: Using gauze alone to secure an arm board is not recommended for a PICC line, as it can cause pressure, restrict circulation, and does not provide adequate stabilization. Specialized securement devices or adhesive dressings are preferred to maintain catheter integrity and prevent complications.

B. Measure the arm circumference above the insertion site daily: Daily measurement of the arm circumference helps detect early signs of swelling, infiltration, or thrombophlebitis, which are potential complications of PICC lines. Monitoring for changes allows prompt intervention and helps ensure safe catheter function.

C. Schedule an MRI postprocedure to verify placement: MRI is not used to verify PICC placement. Catheter tip placement is typically confirmed with chest X-ray or fluoroscopy immediately after insertion, which is the standard method for ensuring correct placement in the superior vena cava.

D. Administer sedation for the procedure: PICC line insertion is generally performed under local anesthesia, not systemic sedation. Routine sedation is not indicated for this minimally invasive procedure unless the client has severe anxiety or special considerations, making it unnecessary in standard care.