A 2-year-old child starts to have a tonic-clonic seizure. The child's jaws are clamped. What is the most important nursing action at this time?
a. Place a padded tongue blade between the child's jaws.
b. Stay with the child and observe his respiratory status.
c. Prepare the suction equipment.
d. Restrain the child to prevent injury.
ANS: B
It is impossible to halt a seizure once it has begun, and no attempt should be made to do so. The nurse must remain calm, stay with the child, and prevent the child from sustaining any harm during the seizure. The nurse should not move or forcefully restrain the child during a tonic-clonic seizure and should not place a solid object between the teeth. Suctioning may be needed but not until the seizure has ended.
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