A nurse is caring for a client who has bulimia nervosa.

Exhibits

Select words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing

and

- 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.

• A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
• B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
• C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
• D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.