The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

Move furniture away from the child.

Place the child in a prone position.

Restrain the child.

Time the seizure

Insert a padded tongue blade in the child's mouth.

Stay with the child

Answer and Explanation

Correct Answer : A,D,F

A.Move furniture away from the child.
Explanation: Creating a safe environment is important during a seizure. Moving furniture away from the child helps prevent injury.
B.Place the child in a prone position.
Explanation: Placing the child in a prone position (face down) is not recommended. The child should be placed on their side to allow for drainage of oral secretions and to prevent aspiration.
C. Restrain the child.
Explanation: Restraint is generally not recommended during a seizure, as it may cause injury to the child or the person providing care. Allow the seizure to run its course, and focus on keeping the environment safe.
D.Time the seizure.
Explanation: Timing the duration of the seizure is important for medical evaluation and management. Note the start and end times of the seizure.
E. Insert a padded tongue blade in the child's mouth.
Explanation: Inserting any object, including a padded tongue blade, into the child's mouth during a seizure is not recommended. This can lead to oral and dental injuries. Maintaining a clear airway and protecting the child from injury are priorities.
F. Stay with the child.
Explanation: Staying with the child provides support and ensures the child's safety during the seizure. It also allows the caregiver to observe and provide information to healthcare professionals.

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Correct Answer is C

Explanation

A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.

A. Sausage-shaped mass palpated in the upper right abdominal quadrant B. The passage of currant jelly-like stools C. Bile-stained fecal emesis D. Failure to pass meconium stool in the first 24 hours after birth

Correct Answer is D

Explanation

A. Sausage-shaped mass palpated in the upper right abdominal quadrant.
Explanation: A sausage-shaped mass in the upper right abdominal quadrant is more indicative of Hirschsprung's disease, not imperforate anus. In Hirschsprung's disease, there is a lack of ganglion cells in the rectum, leading to obstruction and a palpable mass.
B. The passage of currant jelly-like stools.
Explanation: The passage of currant jelly-like stools is characteristic of intussusception, a condition where one portion of the intestine telescopes into another. It is not associated with imperforate anus.
C. Bile-stained fecal emesis.
Explanation: Bile-stained fecal emesis suggests a possible intestinal obstruction or other gastrointestinal issue, but it is not a specific manifestation of imperforate anus. Imperforate anus is primarily characterized by the absence of a normal anal opening.
D. Failure to pass meconium stool in the first 24 hours after birth.
Explanation:
Imperforate anus refers to a congenital condition in which the opening to the anus is absent or improperly formed. One of the clinical manifestations is the failure to pass meconium stool within the first 24 hours after birth. Meconium is the thick, sticky, greenish-black substance that constitutes a newborn's first stools. The absence of meconium passage suggests a potential obstruction.

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The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

Correct Answer is D

Explanation

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