Patient Data Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

Rationale for Correct Choices: Manually ventilate the client with a bag valve mask (BVM): The client’s oxygen saturation is critically low at 40% and respiratory rate is 4 breaths/min, indicating severe hypoventilation and imminent respiratory failure. Immediate ventilation support is essential to prevent hypoxic injury. Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client is at risk of injury from violent movements. Padding the bed rails protects the client from trauma while interventions are performed. Watch the seizure activity and document the time and client movement: Monitoring seizure duration and characteristics is critical for treatment planning and for communicating accurate information to the healthcare team. It also guides decisions about when to administer emergency medications. Rationale for Incorrect Choices: Increase the supplemental oxygen to 10 L/minute via nasal cannula: A nasal cannula can only deliver a maximum of 6 L/minute of oxygen. The client's oxygen saturation is 40%, and a nasal cannula is not a high-flow oxygen delivery system. Stop the IV fluids: There is no immediate indication to stop IV fluids during a seizure unless they interfere with airway management. Maintaining IV access is important for medication administration. Begin chest compressions: Chest compressions are indicated only if the client is pulseless. The client's heart rate is 58 beats/minute, and there is no indication that the client is in cardiac arrest. The client is experiencing respiratory failure, not cardiac arrest.