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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.
Choice B rationale
Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.
Choice C rationale
The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.
Choice D rationale
Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .
Correct Answer is D
Explanation
Choice A rationale
Group therapy can be beneficial for individuals with substance abuse issues as it provides support, reduces isolation, and promotes healthy coping mechanisms. However, it is not the primary intervention for ensuring the health of the baby in a pregnant client on methadone.
Choice B rationale
Discontinuing methadone abruptly is dangerous and can lead to withdrawal symptoms, which can harm both the mother and the fetus. It is important to continue methadone treatment under medical supervision to prevent complications.
Choice C rationale
Genetic testing protocols are important for identifying potential genetic disorders but do not directly address the immediate health needs of a baby born to a mother on methadone treatment.
Choice D rationale
Starting a prenatal care plan as soon as possible is crucial for monitoring the health and development of the fetus, managing the mother's methadone treatment, and providing necessary interventions to ensure the baby's well-being. It is the best approach to ensure a healthy pregnancy.
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