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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Apply elbow immobilizers to both arms is correct. Elbow immobilizers are used to prevent the infant from putting their hands to their mouth, which could disrupt the healing of the surgical site. This is a common practice following cleft palate surgery.

B. Offer a pacifier with glucose syrup is incorrect. Offering a pacifier with glucose syrup is not appropriate, as it could cause harm to the surgical site. The infant should not be allowed to suck on objects that could interfere with healing.

C. Gently cleanse the surgical site with sterile gauze is incorrect. The surgical site should not be cleansed immediately postoperatively unless directed by the provider. Typically, the area is left to heal undisturbed, and cleaning is done with specific guidelines.

D. Place the infant in a supine position is incorrect. While supine positioning is important for infants to prevent sudden infant death syndrome (SIDS), following cleft palate surgery, the infant may need to be placed in an upright position to avoid putting pressure on the surgical site and to reduce the risk of aspiration.

A. Apply cushioning to the edge of the cast using adhesive tape. B. Use a fan to circulate air around the cast. C. Reposition the toddler every 2 hr. D. Check the color and temperature of the toddler's toes.

Correct Answer is D

Explanation

A. Applying cushioning to the edge of the cast using adhesive tape is incorrect. While padding the edges of the cast can prevent skin irritation, it is not the priority in the first few hours after application. Circulatory status must be assessed first.

B. Using a fan to circulate air around the cast is incorrect. Although plaster casts generate heat as they dry and can be uncomfortable, using a fan is not a priority over assessing circulation and neurovascular function.

C. Repositioning the toddler every 2 hours is important to prevent pressure ulcers and discomfort but is not the immediate priority. Ensuring adequate circulation to the extremities takes precedence.

D. Checking the color and temperature of the toddler's toes is correct. A spica cast can impair circulation, leading to complications such as compartment syndrome. Assessing the color and temperature of the toes helps determine if blood flow is adequate. Pale, cool toes could indicate compromised circulation, requiring immediate intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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