QUESTION: "A client with eclampsia begins to experience a seizure. Which of the following would the nurse do first?"
CHOICES
( X ) a.) Pad the side rails.
( X ) b.) Place a pillow under the left buttock.
( X ) c.) Insert a padded tongue blade into the mouth.
( O ) d.) Maintain a patent airway.
RATIONALE: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure. Placing a pillow under the client's left buttock would be of little help during a tonic:clonic seizure. Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
