A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?
Dim the lights in the client's room.
Ensure the call button is within the client's reach.
Pad the side rails of the client's bed.
Place suction equipment at the client's bedside.
The Correct Answer is C
Choice A rationale:
Dimming the lights in the client’s room can help create a calming environment but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice B rationale:
Ensuring the call button is within the client’s reach is important for patient safety and communication, but it is not the priority when implementing seizure precautions for a client with preeclampsia.
Choice C rationale:
Padding the side rails of the client’s bed is the priority when implementing seizure precautions for a client with preeclampsia. This is to protect the client from injury during a seizure.
Choice D rationale:
Placing suction equipment at the client’s bedside is important for maintaining airway patency after a seizure, but it is not the priority when implementing seizure precautions for a client with preeclampsia.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Breastfeeding is not contraindicated following rubella immunization, so this statement is incorrect.
Choice B rationale:
The rubella vaccine is a single-dose vaccine, not a series of three.
Choice C rationale:
Joint pain can occur following rubella immunization, but it’s not a severe side effect that requires immediate medical attention.
Choice D rationale:
Women are advised to avoid pregnancy for at least 1 month following rubella immunization due to the theoretical risk to the fetus, so this statement is correct.
Correct Answer is B
Explanation
Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.
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