A child has a febrile seizure during a well-child visit. Which of the following would be a priority?
Documenting the length and characteristics of the seizure
Using a tongue blade to pry open the child's jaw
Hyperextending the child's head while placing him on his side
Protecting the child from harm during the seizure
The Correct Answer is D
A. Documenting the seizure—its duration, characteristics (tonic-clonic movements, eye deviation, incontinence), and any preceding symptoms is important for medical evaluation and follow-up. However, documentation is secondary; it should be done after the child is safe and the seizure resolves.
B. Using a tongue blade is outdated and unsafe. It can cause oral injury, broken teeth, or airway obstruction. Current guidelines recommend never inserting objects into the mouth during a seizure.
C. Hyperextending the head is dangerous because it may compromise the airway or cervical spine, especially in children with underlying conditions. The proper position is a neutral or slightly tilted head while on the side if possible.
D. Protecting the child from harm is the priority during any seizure. This includes clearing the area of hard or sharp objects, cushioning the head, loosening restrictive clothing, and turning the child onto their side to maintain airway patency and reduce the risk of aspiration. Ensuring the child’s safety addresses the most immediate risk—injury or airway compromise—which aligns with the ABCs of emergency care (Airway, Breathing, Circulation). Once the child is safe, other interventions such as documenting the event and assessing vital signs can follow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. There is no dietary restriction related to milk or dairy products for children with Wilms tumor. Nutritional support is important to maintain growth and healing, especially before and after surgery. This instruction is irrelevant and does not address the critical safety concern.
B. This is the priority nursing action for safety. The sign serves as a visible reminder to all staff, visitors, and caregivers to avoid any abdominal pressure or palpation. Nurses also instruct parents not to handle the child roughly or perform routine abdominal exams before surgery. This intervention significantly reduces the risk of preoperative complications and tumor spread.
C. While IM injections may cause minor bruising or bleeding, they do not increase the risk of tumor rupture. The priority concern is protecting the tumor itself, not avoiding IM injections. Injections may be given safely in other sites as necessary.
D. Venipuncture location does not affect tumor safety. Blood samples can be drawn from upper extremities without increasing the risk of rupture or metastasis. Restricting lower extremity sampling is not a standard precaution for Wilms tumor.
Correct Answer is ["1618"]
Explanation
Step 1: Convert pounds to kilograms
1 kg = 2.2 lb
57 lb ÷ 2.2 = 25.9 kg
Step 2: Use the Holliday-Segar method
- First 10 kg → 100 mL/kg = 10 × 100 = 1000 mL
- Next 10 kg → 50 mL/kg = 10 × 50 = 500 mL
- Remaining weight: 25.9 – 20 = 5.9 kg
→ 5.9 × 20 mL = 118 mL
Step 3: Total daily fluid requirement
1000 + 500 + 118 = 1618 mL/day
Final Answer: 1618 mL
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.