A nurse is reinforcing teaching with a parent of a school-age child who has tonic-clonic seizures. Which of the following statements should the nurse make regarding care during a seizure?
You should offer your child sips of clear liquids.
You should gently restrain your child using both of your arms.
You should place your child's head on a pillow.
You should give rectal diazepam to your child at the onset of the seizure.
The Correct Answer is C
Choice A reason:
The nurse should not offer the child sips of clear liquids during a seizure. During a tonic-clonic seizure, the child's swallowing reflex may be impaired, and giving liquids could lead to aspiration or choking, causing further complications.
Choice B reason:
The nurse should not restrain the child during a seizure using both arms or any other means. Restraint can potentially lead to injury for both the child and the person attempting to restrain them. It is crucial to allow the child to move freely during the seizure to prevent harm.
Choice C reason:
Placing the child's head on a pillow is the correct choice. This positioning helps to protect the child's head from injury during the seizure. The pillow provides a cushioning effect, minimizing the risk of head trauma.
Choice D reason:
The nurse should not instruct the parent to give rectal diazepam to the child at the onset of the seizure unless specifically prescribed by the child's healthcare provider. Diazepam is a medication used to manage seizures, but its administration route and timing should be determined by the child's healthcare provider. Inappropriate use of medication can be dangerous and ineffective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The nurse should include the statement that "This test measures amniotic fluid volume” in the teaching about the biophysical profile (BPP). The rationale for this is that the BPP is a prenatal screening tool that assesses the well-being of the fetus. One of the components of the BPP is the measurement of amniotic fluid volume, which helps to evaluate fetal kidney function and overall fetal health.
Choice B reason:
The nurse should not include the statement about receiving Rh(D) immune globulin prior to the test because it is not directly related to the biophysical profile (BPP). Rh(D) immune globulin is given to Rh-negative pregnant women to prevent hemolytic disease of the newborn (HDN) if the fetus is Rh-positive. While this may be important information during pregnancy, it is not specific to the BPP.
Choice C reason:
The nurse should not include the statement that "This test is used to assess uterine activity” in the teaching about the BPP. The BPP is a test focused on evaluating fetal well-being and not uterine activity. Uterine activity is typically assessed through other methods, such as monitoring contractions during labor.
Choice D reason:
The correct answer is not Choice D. The nurse should not include the statement that "Your bladder needs to be full to perform this test” in the teaching about the BPP. This statement is incorrect because a full bladder is not necessary for the BPP. Instead, the BPP involves the use of ultrasound to assess fetal movements, breathing, muscle tone, and amniotic fluid volume, and a full bladder is not a requirement for this assessment.
Correct Answer is D
Explanation
Choice A reason:
The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.
Choice B reason:
Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.
Choice C reason:
Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.
Choice D reason:
Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.
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