A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down.

Which action(s) should the nurse take? Select all that apply.

A. Place pillows inside the side rails.

Place pillows inside the side rails.

Ask the mother to release the child.

Administer an anticonvulsant medication.

Close the blinds to darken the room.

Monitor the child's airway and tongue.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale

While placing pillows inside the side rails can prevent injury, it may not be effective if the child is having a severe tonic-clonic seizure, as the child could still injure themselves. Padding the entire bed with approved padding is more appropriate in such a case.

Choice B rationale

During a seizure, it is crucial to ensure the child’s safety by asking the mother to release the child to prevent unintentional injury. Holding the child down during a seizure can cause harm to both the child and the mother, and it's important to provide a safe space for the child to move.

Choice C rationale

Administering an anticonvulsant medication can help control the seizure and prevent further convulsions. Medications such as benzodiazepines are often used to treat ongoing seizures and can provide rapid relief.

Choice D rationale

Closing the blinds to darken the room is not directly beneficial during a seizure and does not address the immediate need to protect the child from injury or manage the seizure effectively. While reducing light may help in other conditions, it is not a priority during a seizure.

Choice E rationale

Monitoring the child's airway and tongue is critical to ensure they are not at risk of choking or aspiration during a seizure. Keeping the airway clear and observing for any obstructions can prevent further complications and ensure the child’s safety.

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Correct Answer is A

Explanation

Choice A rationale

Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.

Choice B rationale

Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.

Choice C rationale

Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.

Choice D rationale

Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .

A. Reduction of fever. B. Weight gain. C. Reduction of edema. D. Improved caloric intake.

Correct Answer is C

Explanation

Choice A rationale

Reduction of fever is not the primary goal of albumin therapy. Albumin's role in nephrotic syndrome is to manage severe edema, not to reduce fever, which might be managed by antipyretics if present.

Choice B rationale

Weight gain is typically undesirable in nephrotic syndrome patients due to fluid retention and edema. Albumin therapy aims to reduce edema, potentially decreasing weight as fluid balance improves.

Choice C rationale

Albumin infusion helps reduce edema by increasing plasma oncotic pressure, drawing fluid back into the vascular system. A reduction in edema indicates the therapy’s effectiveness in managing nephrotic syndrome symptoms.

Choice D rationale

Improved caloric intake is not directly affected by albumin infusion. While managing edema might improve overall well-being, albumin’s primary function in this context is fluid balance and reducing swelling.

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A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? Select all that apply. A. Place pillows inside the side rails.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

Correct Answer is A

Explanation

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

Correct Answer is C

Explanation

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A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down.

Which action(s) should the nurse take? Select all that apply.

A. Place pillows inside the side rails.