A 6-year-old child with a history of febrile seizures is brought to the emergency department by parents who re…

Question

A 6-year-old child with a history of febrile seizures is brought to the emergency department by parents who report the child had a generalized tonic-clonic seizure at home that lasted 8 minutes. The child is now postictal and has a temperature of 102.8°F (39.3°C). What is the priority nursing intervention?

Accepted Answer

보기 2: Position the child in a side-lying position and maintain airway patency

During the postictal phase, the child has altered consciousness and risk of airway compromise. The priority is positioning to maintain airway patency and prevent aspiration. Other interventions like fever reduction or history-taking are secondary.

Answer

보기 1: Administer acetaminophen to reduce the fever immediately

Answer

보기 3: Obtain a detailed seizure history from the parents

Answer

보기 4: Prepare for lumbar puncture to rule out meningitis

Concept	Description	Nursing Implication
Febrile Seizure	A seizure associated with fever (usually >100.4°F/38°C) in children 6 months to 5 years without intracranial infection or other cause.	Manage fever, ensure safety during seizure, provide parental education and reassurance.
Postictal State	The period of altered consciousness (confusion, drowsiness) following a seizure.	Priority is airway protection (side-lying position), safety, and continuous monitoring.
ABC Priority Framework	Airway, Breathing, Circulation. The foundational sequence for all emergency assessments and interventions.	Always address airway patency and breathing before any other intervention, regardless of the underlying cause.
Status Epilepticus	A seizure lasting >5 minutes or recurrent seizures without regaining consciousness. A medical emergency.	Requires immediate medication (e.g., benzodiazepines like lorazepam) to stop the seizure in addition to ABC management.

Phase of Seizure Care	Priority Nursing Interventions	Rationale
During Seizure (Ictal)	1. Ensure safety (prevent injury, do not restrain). 2. Time the seizure. 3. Loosen clothing around neck.	Protect from physical harm. Duration guides medical treatment (e.g., need for rescue meds). Facilitate breathing.
Immediately After Seizure (Postictal)	1. Position in side-lying position. 2. Assess airway, breathing, circulation. 3. Provide quiet environment.	Key Point! Prevent aspiration, ensure oxygenation. Allow brain to recover.
After Stabilization	1. Administer antipyretics. 2. Obtain detailed history. 3. Provide patient/family education.	Treat underlying cause (fever). Guide diagnosis and future management. Reduce anxiety and prepare for discharge.

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