A nurse is assisting with collecting data from a 10-month-old in the emergency department.
The Correct Answer is []
Condition the Client Is Most Likely Experiencing:
Tonic-Clonic Seizures: The infant exhibited rhythmic shaking of arms and legs, unresponsiveness during the episode, and postictal sleep, all characteristic of tonic-clonic seizures. These seizures often involve loss of consciousness and rhythmic convulsions of extremities.
Actions to Take:
- Initiate Seizure Precautions: Safety is paramount during and after a seizure to prevent injury. Seizure precautions may include padding the bed rails, ensuring airway patency, and having suction equipment available.
- Keep infant NPO until they are fully awake and alert: Keeping the infant NPO (nothing by mouth) until they are fully awake and alert is crucial to prevent aspiration, which can occur if the infant is fed while still drowsy or lethargic after a seizure.
Parameters to Monitor:
- Level of Consciousness (LOC): Monitoring LOC helps assess the child’s neurological recovery post-seizure and detect worsening neurological status. Persistent lethargy or confusion could indicate prolonged postictal states or complications.
- Motor Ability: Monitoring motor ability is essential to assess for postictal paresis (e.g., Todd's paralysis) or other neurological deficits resulting from the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pneumococcal conjugate vaccine (PCV): This vaccine is generally completed before the age of 5, so it is not typically administered at this stage.
B. Hepatitis B (HBV): The HBV series is usually completed during infancy and early childhood, so it is not needed at 5 years if the child is up to date.
C. Haemophilus influenzae type B (Hib): Hib is typically completed by 18 months of age and is not required for pre-kindergarten.
D. Measles, mumps, and rubella (MMR): A second dose of MMR is typically required at 4-6 years, aligning with pre-kindergarten vaccination schedules.
Correct Answer is A
Explanation
A. Move the child into a side-lying position: This is the priority action to maintain an open airway, promote drainage of vomit, and reduce the risk of aspiration.
B. Remove the child's eyeglasses: While helpful to prevent injury, it is not the priority action during an active seizure.
C. Time the seizure: Timing is important to assess the duration and severity of the seizure, but it does not address immediate safety concerns like aspiration.
D. Place a pillow under the child's head: While this may prevent head injury, repositioning to a side-lying position to prevent aspiration is more critical.
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