The triage nurse is caring for a client at 35 2/7 weeks gestation who has an eclamptic seizure shortly after admission to the unit. What is the nurse's priority action for this client?

Choice A rationale Administering oxygen is an important intervention during the postictal phase to ensure maternal and fetal oxygenation, but it cannot be performed effectively during the height of a generalized tonic-clonic seizure. The nurse must first ensure the patient is not alone and that additional medical assistance is on the way. Once the airway is protected and the seizure subsides, oxygen via a non-rebreather mask at 8 to 10 L/min is appropriate to correct any hypoxia. Choice B rationale Suctioning the mouth during an active seizure is contraindicated because it can cause oral trauma or stimulate the gag reflex, potentially leading to vomiting and aspiration. Suctioning equipment should be prepared and used immediately after the seizure ends to clear secretions or vomitus from the oropharynx. During the seizure, the nurse should turn the client to their side if possible to allow secretions to drain naturally from the mouth and maintain a patent airway. Choice C rationale Safety is the absolute priority during an eclamptic seizure. The nurse must remain with the client to prevent injury, such as falling out of bed, and must call for help to mobilize the rapid response team and obtain emergency medications like magnesium sulfate. The nurse should observe the seizure characteristics and timing while ensuring the environment is safe. Leaving the patient alone during a seizure increases the risk of airway obstruction, trauma, and unobserved status epilepticus. Choice D rationale Inserting an oral airway or any object into the mouth during an active seizure is strictly prohibited. It can lead to broken teeth, jaw injury, or complete airway obstruction if the object is pushed back into the throat. The masseter muscles are often tightly clenched during the tonic phase of a seizure. The nurse should never force anything between the teeth. Airway management focuses on positioning and postictal suctioning rather than mechanical insertion during the convulsive episode.