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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A) Scarlet fever is not a nationally notifiable condition.
B) Rotavirus is not a nationally notifiable condition.
C) Erythema infectiosum (Fifth disease) is not a nationally notifiable condition.
D) Pertussis, also known as whooping cough, is a nationally notifiable condition, meaning healthcare providers are required to report cases of pertussis to public health authorities for surveillance and control purposes.
Correct Answer is D
Explanation
Rationale:
A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
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