Reference no: EM133565057

Mrs. Diana is a 21-year- old female. Admitted 4 days ago at the stepdown unit with headache and seizure activities. Medical diagnosis: seizure disorder. Medical history of malignant brain tumor, HTN, migraine, current every day smoker (1 pack per day). Vital signs are as follows: T 98.2 oral, RR 18, 02 sat 97% on RA, P 98, BP 130/68. Labs: CBC unremarkable, except for platelet of 118, remainder of labs are unremarkable. The Doctor orders the following: Dilantin 100 mg PO Q 8 hrs. Ativan 2 mg IV push, heparin 5000 units subcutaneous BID. CT of brain shows Prominent brain tumor to frontal lobe. IV access: Right forearm #20 saline lock. The patient's last seizure was 1 day ago during admission. The Nurse's aide called for the nurse to come to the patient's room STAT and found the patient actively seizing.

1. What is the first action the nurse should take?

2. What position should the nurse place Mrs. Dina post-ictal?

3. Which medications should the nurse give first?

4. Which medication should the nurse hold?

5. What critical change should the nurse monitor the patient for and report to the doctor?