A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse’s priority?
Loosen restrictive clothing.
Position the child side-lying.
Place a pillow under the child’s head.
Clear the area of hazards.
The Correct Answer is B
Choice A rationale
Loosening restrictive clothing can help ensure the child is comfortable and can breathe easily during a seizure. However, it is not the priority action. The primary concern during a tonic- clonic seizure is to maintain the child’s airway and prevent aspiration, especially if the child is vomiting.
Choice B rationale
Positioning the child side-lying is the priority action. This position helps maintain an open airway and allows any vomit or secretions to drain out of the mouth, reducing the risk of aspiration.
Choice C rationale
Placing a pillow under the child’s head can provide comfort and prevent head injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
Choice D rationale
Clearing the area of hazards is important to prevent injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
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Correct Answer is A
Explanation
Choice A rationale
A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.
Choice B rationale
While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.
Choice C rationale
The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.
Choice D rationale
The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A.
Correct Answer is D
Explanation
Choice A rationale
Encouraging the child to talk about the procedure is important for emotional support, but it is not the most critical assessment immediately after a cardiac catheterization. The priority is to monitor for potential complications.
Choice B rationale
Confirming to the child that the procedure has been completed is important for reassurance, but it is not the most critical assessment. The priority is to monitor for potential complications.
Choice C rationale
Gradually allowing the child to adapt to the lighted surroundings is not relevant to the immediate post-procedure care. The priority is to monitor for potential complications.
Choice D rationale
Checking pedal pulses frequently is the most important assessment after a cardiac catheterization via the femoral artery. It helps to ensure that there is adequate blood flow to the lower extremities and to detect any signs of arterial obstruction or complications at the catheter insertion site.