# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542446 > language: ko > subject: Child Health ## 문제 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? ## 보기 1. Administer acetaminophen to reduce the fever immediately 2. Position the child in a side-lying position and maintain airway patency **✔ 정답** 3. Obtain a detailed seizure history from the parents 4. Prepare for lumbar puncture to rule out meningitis **정답: 2** ## 해설 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. ## 심화 해설 Understanding the Priority: Airway, Breathing, Circulation The immediate postictal phase following a generalized tonic-clonic seizure presents the highest risk for airway compromise. During the seizure, excessive salivation, possible vomiting, and relaxation of the tongue and pharyngeal muscles can obstruct the airway. The postictal state is also characterized by a depressed level of consciousness, which impairs protective airway reflexes. The foundational principle in any seizure emergency, as reinforced by clinical guidelines, is to first secure the airway, breathing, and circulation (ABCs) before addressing the underlying trigger, such as fever . Positioning the child in a side-lying position immediately helps maintain airway patency by allowing secretions to drain via gravity and preventing the tongue from falling back, directly mitigating the risk of aspiration and hypoxia. Why Other Interventions Are Not the Immediate Priority While fever is the defining trigger for this event, and the child’s temperature is 102.8°F (39.3°C), administering an antipyretic like acetaminophen is not the first action. The fever has already triggered the seizure, and the immediate threat is no longer the temperature itself but the postictal airway vulnerability. Antipyretics are important for patient comfort and to treat the source of the fever but do not have a rapid enough onset to affect the immediate post-seizure course . A detailed seizure history is a critical component of diagnosis, helping to classify the event as a simple or complex febrile seizure, but it is a secondary assessment task once the child is physiologically stable . Preparing for a lumbar puncture is a key consideration in a febrile, postictal child to rule out meningitis or encephalitis, especially in complex presentations. However, this is a diagnostic procedure that follows, not precedes, the initial stabilization and assessment of the child’s vital functions . Clinical Context of Febrile Seizures Febrile seizures are the most common neurological emergency in children, typically occurring between 6 months and 5 years of age, with a worldwide prevalence of 2%-5% . The case describes a seizure lasting 8 minutes, which classifies it as a complex febrile seizure based on duration (greater than 5 minutes) and focal or prolonged postictal features. Febrile status epilepticus, a seizure lasting longer than 30 minutes, occurs in approximately 5% of febrile seizure cases and represents a more severe spectrum of the condition . The pathophysiology linking fever to seizures is not fully understood, but research suggests that fever-induced hyperventilation and resulting hypocapnia may play a precipitating role, which is why maintaining adequate ventilation is a core physiological concern . The priority nursing intervention therefore directly targets the most life-threatening risk: airway obstruction leading to hypoxia, which aligns with the first step in managing any acute convulsive event in a child . ## 임상 시나리오 Postictal Airway Management in Febrile SeizureImmediate nursing priority following a generalized seizure The highest priority in the postictal phase is securing the airway per ABCs. A depressed level of consciousness impairs protective reflexes, increasing the risk of aspiration from excessive saliva or vomit. Position the child in a side-lying position immediately. This allows secretions to drain via gravity and prevents the tongue from obstructing the pharynx, directly mitigating hypoxia risk. CautionDo not prioritize antipyretic administration during the immediate postictal period. The seizure has already occurred, and the onset of action for medications like acetaminophen is too slow to address the acute airway vulnerability. Treating the fever is secondary to maintaining patency and oxygenation. ## 핵심 개념 - **Postictal State** — The altered state of consciousness following a seizure, characterized by confusion, drowsiness, and risk of airway compromise due to depressed protective reflexes. - **Generalized Tonic-Clonic Seizure** — A seizure type involving stiffening (tonic) and rhythmic jerking (clonic) of muscles, often with loss of consciousness and potential for apnea and excessive salivation. - **Febrile Seizure** — A convulsion in a young child triggered by a rapid rise in body temperature, typically from an infection, without underlying intracranial cause. - **ABCs (Airway, Breathing, Circulation)** — The foundational priority framework in emergency care, mandating that airway patency and ventilation are secured before addressing other issues. - **Aspiration** — The inhalation of foreign material (e.g., saliva, vomit) into the airways, a major risk during and after a seizure due to impaired swallowing and consciousness. ## 같은 주제 문제 - [A 6-year-old child is brought to the emergency department by parents who report the child …](https://mymerci.kr/pages/nclex_q.php?qn_id=542443) - [A 6-year-old child is brought to the emergency department by parents who report the child …](https://mymerci.kr/pages/nclex_q.php?qn_id=542444) - [A 3-year-old toddler is brought to the clinic by caregivers who report a brief seizure epi…](https://mymerci.kr/pages/nclex_q.php?qn_id=542445) - [A 12-year-old adolescent with a history of complex partial seizures is brought to the emer…](https://mymerci.kr/pages/nclex_q.php?qn_id=542447) - [A 7-year-old child with epilepsy is brought to the emergency department by parents who rep…](https://mymerci.kr/pages/nclex_q.php?qn_id=542448) - [A 3-year-old toddler with a history of febrile seizures is brought to the emergency depart…](https://mymerci.kr/pages/nclex_q.php?qn_id=542449) - [A 10-year-old child with a history of generalized tonic-clonic seizures is brought to the …](https://mymerci.kr/pages/nclex_q.php?qn_id=542450) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._