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