A nurse is caring for a 12-month-old male toddler in the emergency department (ED).
Which of the following actions should the nurse prioritize for the toddler experiencing a febrile seizure?
Administer acetaminophen 15 mg/kg PO to reduce fever.
Initiate an intravenous line for fluid administration.
Place the toddler in a side-lying position during the seizure.
Administer lorazepam 0.1 mg/kg IV as prescribed.
The Correct Answer is C
Choice A rationale: Administering acetaminophen can help reduce fever, but this is a secondary intervention. Febrile seizures are typically benign and self-limited, lasting under 5 minutes. Immediate priorities during an active seizure include airway patency and safety. Antipyretics do not rapidly reverse seizure activity and do not prevent recurrence. While acetaminophen helps lower hypothalamic set point through prostaglandin inhibition, its action does not address seizure physiology directly.
Choice B rationale: Initiating IV fluids might be considered for prolonged seizures, dehydration, or postictal recovery support, but this toddler is hemodynamically stable and alert. His oxygen saturation is 99%, capillary perfusion is intact, and there’s no clinical evidence of volume depletion. IV access is not a priority during the seizure itself and may pose a safety risk if attempted prematurely. Fluids also do not directly influence seizure cessation in febrile episodes.
Choice C rationale: Side-lying positioning ensures airway patency and reduces the risk of aspiration if vomiting or oral secretions occur during the seizure. It protects against airway obstruction and is a key component of seizure first-aid across all pediatric age groups. This posture also minimizes injury and allows secretions to drain. It is the top priority during seizure activity because it supports basic airway management, which aligns with pediatric resuscitation protocols.
Choice D rationale: Lorazepam administration is typically reserved for seizures lasting longer than 5 minutes or those that recur within a short window, known as status epilepticus. Febrile seizures under 5 minutes, as in this case, do not warrant pharmacologic intervention with benzodiazepines due to potential respiratory depression and sedation risks. Lorazepam acts via GABA-A receptor agonism to suppress neuronal hyperexcitability, but its use must be guided by seizure duration and persistence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The external auditory canal in a toddler is shorter and has an upward curve compared to an adult. Pulling the pinna down and back straightens this canal, allowing the medication to flow more effectively and reach the eardrum. This maneuver optimizes drug delivery by aligning the auditory canal for better access and absorption. This is a crucial anatomical consideration for medication administration in young children.
Choice B rationale
Inserting the dropper into the ear canal can cause significant trauma to the delicate tympanic membrane or the canal walls. The dropper tip may be sharp or firm, and forceful insertion can lead to pain, bleeding, or perforation of the eardrum. This action is contraindicated as it poses a significant risk of injury to the child's auditory structures. The drops should be instilled just inside the opening.
Choice C rationale
Administering cold ear drops can cause a caloric reaction, leading to dizziness, nausea, and vertigo. The sudden temperature change stimulates the vestibular system in the inner ear, causing a temporary imbalance. The drops should be warmed to body temperature by holding the container in the hands for a few minutes before administration to prevent this adverse physiological response.
Choice D rationale
Massaging the area behind the ear, over the mastoid bone, can be painful and is not an effective method for distributing otic medication. The drops are meant to act locally within the ear canal. Gentle pressure on the tragus, the small cartilage flap in front of the ear canal, can help to push the medication deeper into the canal after instillation, but massaging behind the ear is not indicated.
Correct Answer is D
Explanation
Choice A rationale
Providing discharge education would be inappropriate as a first action when the child is exhibiting signs of potential airway compromise. Difficulty swallowing, known as dysphagia, and throat secretions could indicate post-operative swelling or bleeding. The priority is to address the immediate physiological needs of the child and rule out a complication before providing any education.
Choice B rationale
A diversionary activity is not the most immediate or appropriate intervention for a child with difficulty swallowing and throat secretions. While providing comfort and distraction can be helpful, it does not address the underlying physiological problem, which could be a serious post-surgical complication such as laryngeal edema or hemorrhage. The first action must be an assessment.
Choice C rationale
Offering a popsicle could worsen the situation. It may be a routine post-tonsillectomy comfort measure, but if the child is having difficulty swallowing, giving them something to eat or drink poses a significant risk of aspiration. This action should be deferred until a full assessment is conducted and the medical team determines it is safe for the child to swallow.
Choice D rationale
The difficulty swallowing and presence of secretions in the throat after a tonsillectomy can be an indicator of pain, swelling, or bleeding. The nurse should first administer pain medication to alleviate the child's discomfort, which may improve their ability to swallow and manage secretions. After administering the medication, the nurse should notify the surgeon to evaluate for complications.
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.