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An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

A.

A client who is at 33 weeks of gestation and has severe gestational hypertension

B.

A client who is at 16 weeks of gestation and has a hydatidiform mole

C.

A client who is at 28 weeks of gestation and is experiencing vaginal bleeding

D.

A client who is at 36 weeks of gestation and has a positive group B streptococcal culture

Answer and Explanation

The Correct Answer is A

- A. Correct. The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a lifethreatening complication that involves seizures. 

- B. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures. 

- C. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures. 
 
- D. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures. 
 


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Related Questions

Correct Answer is B

Explanation

Allow for frequent rest periods throughout the day.

  • A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
  • B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
  • C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain. - D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.

Correct Answer is D

Explanation

Have the client wear a surgical mask while being transported outside the room.

  • A. Initiate contact precautions for the client upon admission. This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
  • B. Restrict visitors from entering the client's room during hospitalization. This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
  • C. Wear a surgical mask while providing care for the client. This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
  • D. Have the client wear a surgical mask while being transported outside the room. This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.

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