A nurse is caring for a client who has preeclampsia.
Which of the following actions is the nurse’s priority when implementing seizure precautions?

Ensure the call button is within the client’s reach

Place suction equipment at the client’s bedside

Dim the lights in the client’s room

Pad the side rails of the client’s bed

Answer and Explanation

The Correct Answer is B

Choice A rationale: Ensuring the call button is within the client's reach is important for general patient safety and communication, but it is not the highest priority for seizure precautions.

Choice B rationale: Placing suction equipment at the client's bedside is crucial for managing airway secretions during a seizure. Having suction equipment readily available ensures that the client's airway can be cleared promptly, which is vital for maintaining breathing and preventing aspiration.

Choice C rationale: Dimming the lights in the client's room can help reduce stimuli that may trigger seizures, but it is not the most urgent action to take when implementing seizure precautions.

Choice D rationale: Padding the side rails of the client's bed is important to prevent injury during a seizure, but ensuring that suction equipment is available takes priority to maintain airway patency and prevent complications.

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Correct Answer is C

Explanation

Choice A rationale
While demonstrating proper bathing of the infant is an important skill for new mothers, it is not typically a primary goal during the taking-in phase. This phase is characterized by the mother’s need to review her birth experience and begin to process her new role.
Choice B rationale
Verbalizing appropriate car seat safety is important, but it is not a primary goal during the taking-in phase. This phase is more focused on the mother’s internal processing of her birth experience.

Choice C rationale
This is the correct answer. Having adequate nutritional intake is a key goal during the taking-in phase. Good nutrition is essential for healing and recovery after childbirth, as well as for breastfeeding.
Choice D rationale
Identifying necessary family roles is an important part of adjusting to parenthood, but it is not a primary goal during the taking-in phase. This phase is more about the mother’s personal adjustment and recovery.

A. Check the newborn’s identification using the crib card. B. Require visitors to wear an identification band. C. Replace the infant’s identification band after his name has been recorded. D. Obtain an imprint of the infant’s feet prior to taking him to the nursery.

Correct Answer is D

Explanation

Choice A rationale
Checking the newborn’s identification using the crib card is not the most reliable method. The crib card could be misplaced or switched accidentally.
Choice B rationale
Requiring visitors to wear an identification band does not directly ensure the proper identification of newborns. While it can enhance the security of the unit, it does not link the newborn to their correct parents.
Choice C rationale
Replacing the infant’s identification band after his name has been recorded is not the most effective method. The identification band should be placed on the newborn immediately after birth to prevent mix-ups.

Choice D rationale
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is the correct answer. This method is a reliable way to identify newborns. The footprints, along with the mother’s fingerprints, are often taken within the first hour after birth. This can be used for identification throughout the hospital stay.

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A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse’s priority when implementing seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who has preeclampsia.
Which of the following actions is the nurse’s priority when implementing seizure precautions?