A nurse is caring for a school-age child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Prevent movement of the child's extremities.
Administer magnesium sulfate to the child.
Put a tongue blade between the child's teeth.
Place a folded blanket under the child's head.
The Correct Answer is D
A. Prevent movement of the child's extremities is incorrect. Attempting to prevent movement during a tonic-clonic seizure is unsafe. The nurse should avoid restraining the child, as this can cause injury. The focus should be on ensuring safety during the seizure.
B. Administer magnesium sulfate to the child is incorrect. Magnesium sulfate is used for certain conditions, such as preeclampsia in pregnant women or seizures due to eclampsia, but it is not typically used to manage tonic-clonic seizures in children. Anticonvulsant medications or emergency interventions are more appropriate.
C. Put a tongue blade between the child's teeth is incorrect. Inserting a tongue blade or any object into the mouth during a seizure is dangerous, as it can lead to injury to the mouth, teeth, or airway. The nurse should not attempt to put anything in the child's mouth.
D. Place a folded blanket under the child's head is correct. The priority during a tonic-clonic seizure is to protect the child from injury. Placing a folded blanket or soft padding under the head helps prevent head trauma if the child falls to the ground during the seizure. The nurse should also ensure the environment is clear of sharp objects.
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Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
- Maintain infant on continuous pulse oximetry: Continuous monitoring of oxygen saturation is essential for assessing the infant's respiratory status.
- Maintain infant in supine position: Keeping the infant in a supine position is generally safe and helps with monitoring and care.
- Offer small, frequent feedings: Small, frequent feedings can help maintain the infant's nutritional status and prevent dehydration.
- Monitor intake and output: Monitoring intake and output is crucial for assessing the infant's fluid balance and overall health.
- Initiate a peripheral IV line: Establishing IV access is important for administering medications and fluids as needed.
Provider prescription
Anticipated
Contraindicated
Maintain infant on continuous pulse oximetry.
✓
Maintain infant in supine position.
✓
Offer small, frequent feedings.
✓
Monitor intake and output.
✓
Initiate a peripheral IV line.
✓
Prepare the infant for a chest x-ray.
✓
Correct Answer is D
Explanation
A. Mix the medication in a bottle of formula is incorrect. Mixing medication in a bottle of formula may cause the infant to not receive the full dose of the medication if they do not finish the bottle. It also creates the risk of the infant associating the medication with the feeding, which could lead to future feeding issues.
B. Mix the medication with a small amount of honey is incorrect. Honey should not be given to infants under 1 year of age due to the risk of botulism. Additionally, mixing medication with any substance should be avoided unless directed by the provider.
C. Place the medication in the back of the infant's throat using a dropper is incorrect. Administering medication in the back of the throat with a dropper can be dangerous and may lead to choking. The medication should be given in a controlled manner.
D. Place the medication in an oral syringe is correct. An oral syringe is the safest method for administering medication to an infant. It allows the nurse to measure the dose accurately and administer the medication slowly to ensure it is swallowed safely.
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