A nurse is caring for a 4-year-old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make?

A. Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate.

B. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure.

C. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively.

D. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.

A. "My belly doesn't hurt anymore."

- This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.

B. "I am hungry and thirsty."

- While it's normal for a child to feel hungry and thirsty, especially if they have been experiencing nausea and vomiting, this statement is not necessarily concerning on its own. However, in the context of suspected appendicitis and severe right lower quadrant pain, it's important for the child to remain NPO (nothing by mouth) to prevent complications in case surgery is needed.

C. "I'm tired and want to take a nap."

- Feeling tired and wanting to rest is not uncommon, especially if the child has been experiencing discomfort or pain for a prolonged period. While this statement may indicate fatigue, it's not inherently concerning in the context of suspected appendicitis. However, it's important for the nurse to monitor the child's energy level and overall condition.

D. "I am scared and I want to go home."

- It's understandable for a child to feel scared or anxious, particularly when facing a medical procedure such as surgery. While this statement reflects the child's emotions, it doesn't necessarily indicate a change in their medical condition. However, it's important for the nurse to address the child's fears and provide emotional support while ensuring that the child receives appropriate medical care.