The nurse, working in the emergency room, admits a 13-month-old child reported by the parents to have had a clonic–tonic seizure at home with no history of a seizure disorder. What is the nurse's priority intervention?
A) Monitor serum phenytoin level.
B) Take the child's temperature.
C) Place the child in a tepid bath.
D) Administer an antipyretic medication.
B
Feedback:
The first action of the nurse is to measure body temperature to determine whether the child has a fever, which could explain why the seizure occurred. Febrile seizures are common in young children. They are related to very high fevers and usually involve clonic–tonic seizure. Febrile seizures most frequently occur in children and they are usually self-limited and do not reappear. The nurse would not treat a fever by administering antipyretics or providing a tepid bath until temperature is measured. There would be no reason to check phenytoin levels if the child has no history of seizure disorder.
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