A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take?

A. Attempting to force an object into the oral cavity during muscle contraction causes dental trauma or jaw fractures. It significantly increases the risk of aspiration if the object breaks or triggers a gag reflex. Modern clinical guidelines strictly prohibit the insertion of any device into the mouth during active convulsions. Airway patency is maintained by placing the client in a lateral position. B. Tracking the exact duration of the ictal phase is a critical nursing responsibility for clinical assessment. This data determines the necessity for emergency benzodiazepines if the event lasts longer than 5 minutes. Precise timing helps differentiate between a self-limiting seizure and dangerous status epilepticus. The nurse must record the start and end times to guide medical intervention. C. Lowering the side rails during a seizure increases the risk of the client falling from the height of the bed. Standard seizure precautions require that side rails remain raised and should be padded to prevent blunt force trauma. Ensuring the patient stays within the safe boundaries of the bed is a primary safety goal. D. Physical restraints can cause severe musculoskeletal injuries such as fractures or dislocations during the forceful involuntary movements of the clonic phase. Restricting the extremities creates unnecessary resistance against powerful muscle contractions. The nurse should clear the immediate area of hard objects rather than holding the client down.