A nurse is caring for a child experiencing a seizure. Which of the following actions is the nurse's priority?
Place a pillow under the child's head.
Loosen restrictive clothing
Clear the area of hazards.
Position the child on his side.
The Correct Answer is C
A. Place a pillow under the child's head: Supporting the head can prevent minor trauma during a seizure, but it does not address immediate risks in the environment that could cause serious injury.
B. Loosen restrictive clothing: Loosening tight clothing can improve comfort and prevent airway restriction, yet it is secondary to ensuring the child’s safety from environmental hazards.
C. Clear the area of hazards: The priority during a seizure is to prevent injury. Removing sharp objects, furniture, or other obstacles protects the child from trauma caused by uncontrolled movements and ensures a safer environment while other supportive interventions are implemented.
D. Position the child on his side: Placing the child on their side helps maintain airway patency and reduces the risk of aspiration. While essential, it is most effective after the immediate environment is made safe, making hazard clearance the initial priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Unruptured membranes: Internal fetal monitoring devices, such as a fetal scalp electrode or intrauterine pressure catheter, require rupture of membranes to access the amniotic fluid and fetal scalp. Attempting insertion with intact membranes increases the risk of trauma, infection, and procedural failure.
B. Cervix is dilated to 4 cm: A cervical dilation of 4 cm is typically sufficient for safe internal monitoring once membranes are ruptured. The degree of dilation itself does not prevent application, provided other criteria for internal monitoring are met.
C. External monitors are currently being used: External monitoring is noninvasive and can be used concurrently or as an initial step. The presence of external monitors does not contraindicate internal monitoring; internal devices are considered when more accurate fetal heart rate or contraction data are needed.
D. Fetus has a known heart defect: Some fetal heart defects may alter baseline heart rate or variability but do not automatically preclude the use of internal monitoring devices. Internal monitoring can still be applied safely if membranes are ruptured and other clinical criteria are met.
Correct Answer is B
Explanation
A. Moderate lochia rubra is an expected finding in the early postpartum period as the uterus sheds decidual tissue and blood. This finding alone does not specifically indicate bladder distention or urinary retention.
B. A fundus positioned above the umbilicus in the early postpartum period suggests uterine displacement, commonly caused by a distended bladder. Bladder fullness prevents effective uterine contraction and can elevate and deviate the fundus.
C. Moderate labial swelling is common after vaginal delivery due to tissue trauma and vascular congestion. While it may cause discomfort with voiding, it does not indicate the physiologic need to urinate.
D. A blood pressure of 130/84 is slightly elevated but can be normal postpartum due to pain, fluid shifts, or stress. This vital sign change is not associated with bladder distention or urinary retention.
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