A nurse is assessing a client with eclampsia who is having a seizure.

Which of the following actions should the nurse take first?

Protein excretion of 450 mg indicates proteinuria.Proteinuria is the presence of excess protein in the urine, which can be a sign of kidney damage or disease.Normal protein excretion in a 24-hour urine collection is less than 150 mg.

Choice A is wrong because protein excretion of 150 mg is within the normal range.

Choice B is wrong because protein excretion of 250 mg is slightly above the normal range, but not enough to indicate proteinuria.

Choice C is wrong because protein excretion of 350 mg is also above the normal range, but not enough to indicate proteinuria.

Preeclampsia is a condition that affects some pregnant women, usually after 20 weeks of pregnancy.It causes high blood pressure and proteinuria, which can harm both the mother and the baby.A 24-hour urine collection is a simple lab test that measures what’s in the urine and checks kidney function.The test is done by collecting all the urine passed in a 24-hour period in a special container that must be kept cool until returned to the lab.

Turn the client to the side.This is because turning the client to the side will prevent aspiration and maintain a patent airway during a seizure.

Some possible explanations for the other choices are:

• Choice B. Insert an oral airway.This is wrong because inserting an oral airway during a seizure can cause injury to the client’s mouth or teeth, and it can also stimulate the gag reflex and increase the risk of vomiting and aspiration.

• Choice C. Administer oxygen via face mask.This is wrong because administering oxygen via face mask during a seizure can be difficult and ineffective, as the client may not be able to breathe through the mask or may dislodge it with their movements.Oxygen can be given after the seizure has stopped, if needed.

• Choice D. Document the duration of the seizure.

This is wrong because documenting the duration of the seizure is not a priority action during a seizure.The nurse should first ensure the client’s safety and airway patency, and then document the seizure characteristics after it has ended.