A nurse is taking care of child who is having epilepsy. What nurse should do immediately?

AIIMS Delhi NO- 2019

Child Health Nursing (Pediatrics)

Medium

Appeared in: AIIMS Delhi NO- 2019

Explanation

The highest priority in managing an active seizure is to maintain a patent airway and ensure patient safety.
Placing the child in a side-lying (recovery) position is the most effective immediate action to prevent the tongue from obstructing the airway.
This position also facilitates the drainage of saliva and any potential vomitus, preventing aspiration into the lungs, which is a major risk during a seizure.
This intervention directly addresses the 'A' (Airway) and 'B' (Breathing) of the ABCs of emergency care.

Option B: Administering oxygen is a secondary intervention. It is ineffective if the airway is obstructed by the tongue or secretions.
Option C: Taking no action is negligent and unsafe. The nurse has a duty to protect the patient from harm.
Option D: Informing the doctor and documenting are important tasks, but they are not the immediate priority. Patient safety and physiological stability (like a clear airway) must be established first.

Clinical Relevance

Nursing practice connection: Use the key finding related to Immediate nursing management of an active seizure to guide bedside assessment, documentation, and the next nursing action.
This question highlights the core nursing principle of prioritizing patient safety and the ABCs (Airway, Breathing, Circulation) in an emergency.
Nurses must be prepared to act immediately during a seizure. Seizure precautions, such as padded side rails and having suction equipment ready, are essential for at-risk patients.
A seizure lasting more than 5 minutes, or multiple seizures without regaining consciousness in between, is a medical emergency known as status epilepticus, which requires immediate medical intervention to prevent brain damage.

How to Approach the Question

Identify the question type: This is a priority-based question asking for the immediate nursing action.
Analyze the clinical situation: A child is actively having a seizure, which is a medical emergency.
Apply the ABCs and Safety framework: In any emergency, assess Airway, Breathing, and Circulation first, while also ensuring the patient is safe from environmental hazards.
Evaluate the options based on this framework: Option A directly addresses Airway and Safety by positioning the child to prevent aspiration. The other options (oxygen, recording, informing the doctor) are important but are secondary to establishing a patent airway and ensuring immediate physical safety.
Select the option that represents the most critical, life-saving intervention that must be performed first.

Concept Tested & Keywords

Concept Tested: Immediate nursing management of an active seizure.
Stem keywords: nurse, child, epilepsy, immediately
Lead-in keywords: What nurse should do immediately?
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.
Negative lead-in flag: false

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