At hand-off report the off-going nurse states that the patient demonstrated clonus on her last assessment.What action by the on-coming nurse takes priority?

Question

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Clonus (repeated tapping when the foot is dorsiflexed)is usually associated with pregnancy-induced hypertension and may precede a seizure.The nurse should place the woman on seizure precautions.Vital signs should be assessed frequently,but this is not the priority.There is no need at this point for cesarean delivery,although that is possible.Assessing for pain is important but does not take priority over a safety measure.

At Hand-Off Report the Off-Going Nurse States That the Patient