A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)
Loosen restrictive clothing.
Hyperextend the child's neck.
Time the seizure episode.
Place the child in a side-lying position.
Restrain the child.
Correct Answer : A,C,D
Rationale:
A) Loosening restrictive clothing prevents injury during the seizure.
B) Hyperextending the child's neck can cause injury and should be avoided. Instead, the neck should be supported to maintain an open airway.
C) Timing the seizure episode is important for documenting the duration and for providing accurate information to healthcare providers.
D) Placing the child in a side-lying position helps prevent aspiration and maintains an open airway during the seizure.
E) Restraint should not be applied during a seizure unless absolutely necessary to prevent injury to the child or others.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A) Rubbing betadine on the infant's incisions is not typically done after surgical repair of a cleft lip and palate, as it can cause irritation and delay wound healing.
B) Placing the infant in a prone position for an extended period is not recommended after cleft lip and palate repair surgery, as it may increase the risk of airway obstruction and compromise wound healing.
C) Weighing the infant daily using the same scale helps monitor for changes in fluid status and overall health status following surgery.
D) Suctioning the infant's nose and mouth may be necessary to maintain airway patency, but it should be done judiciously to avoid trauma to the surgical site.
Correct Answer is C
Explanation
Rationale:
A) It's important to burp a baby mid-feed and after the feed to prevent discomfort, especially for a baby with a cleft lip.
B) Using a wide-based nipple may be more appropriate for a baby with a cleft lip to help with proper latch and feeding.
C) Holding the baby in an upright position during feedings can help prevent milk from entering the nasal passages, which is important for babies with cleft lip.
D) Encouraging the baby to maintain relaxed cheeks during feeding may not be applicable for a baby with a cleft lip, as proper positioning and latch are more critical.
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