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1. Medical Conditions: Priority Action for a Client Who is Having a Seizure
A. Airway breathing circulation (ABC) framework
-The ABC framework identifies, in order, the three basic needs for sustaining life
-An open airway is necessary for breathing, so it is the highest priority
-Breathing is necessary for oxygenation of the blood to occur
-Circulation is necessary for oxygenated blood to reach the body’s tissues
-The severity of manifestations should also be considered when determining
priorities. A severe circulation problem can take priority over a minor breathing
problem
-Some frameworks also include “D†for disability and “E†for exposure
B. Seizure Precautions
-Make sure rescue equipment is at the bedside including oxygen, an oral airway,
suction equipment, and padding for the side rails. Clients at high risk for
generalized seizures should have a saline lock in place for immediate access.
2. Fetal Assessment During Labor: Applying an External Transducer
A. Location of the fetus’s back to assess for fetal heart tones
-Vertex presentation: fetal heart tones should be assessed below the client’s
umbilicus in either the right or left lower quadrant of the abdomen
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