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 D
Explanation
Choice A rationale
Explaining the difference between right and wrong is a developmental task expected of older children, typically preschoolers or early school-aged children. Toddlers are still developing their understanding of rules and consequences.
Choice B rationale
Printing letters and numbers is a skill expected of preschoolers or early school-aged children. Toddlers are still developing fine motor skills and are not yet capable of printing letters and numbers.
Choice C rationale
Cooperating in doing simple chores is a developmental task that can be expected of toddlers. However, it is not as specific or significant as the ability to separate easily from the primary caregiver for short periods of time, which is a key developmental milestone for toddlers.
Choice D rationale
Separating easily from the primary caregiver for short periods of time is an important developmental milestone for toddlers. It indicates that the child is developing a sense of independence and trust in their environment, which is crucial for their social and emotional development.
Correct Answer is D
Explanation
Choice A rationale
Erikson’s stage of initiative versus guilt occurs in preschool-aged children (3-5 years), not toddlers.
Choice B rationale
Imaginary playmates are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice C rationale
Demonstrations of sexual curiosity are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice D rationale
Negative behaviors characterized by the need for autonomy are typical in toddlers. This stage, according to Erikson, is autonomy versus shame and doubt, where toddlers strive for independence and self-control.