A 2-year-old has a tonic-clonic seizure while in the hospital crib. The child's jaws are clamped. Which is the most important nursing action at this time?
1. Place a padded tongue blade between the child's jaws.
2. Stay with the child and observe his respiratory status.
3. Prepare the suction equipment.
4. Restrain the child to prevent injury.
2
Rationale
1. Be sure nothing is placed in the child's mouth during a seizure.
2. During a seizure, the nurse remains with the child, watching for complications. The child's respiratory rate should be monitored.
3. Suction equipment already should be set up at the bedside before a seizure begins.
4. The child should not be restrained during a seizure.
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