RN Nursing · Neurological Disorders in Children · Practice question
A nurse is caring for a 7-year-old child who has just experienced a tonic-clonic seizure. Which clinical sign should the nurse prioritize monitoring during the tonic phase to ensure immediate safety?
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Assess for unilateral jerking of limbs which indicates a focal clonic seizure.
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Check for excessive drooling and lip-smacking as indicators of focal motor seizure activity.
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✓
Observe cyanosis and apnea as breathing may stop during the tonic phase.
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Look for sudden loss of muscle tone leading to collapse, typical of atonic seizures.
Answer & explanation
Correct: Observe cyanosis and apnea as breathing may stop during the tonic phase.
During the tonic phase of a tonic-clonic seizure, the muscles of the entire body, including the respiratory muscles, contract rigidly. This sustained muscular contraction can cause breathing to stop temporarily, resulting in apnea and subsequent cyanosis due to lack of oxygenation. Monitoring for cyanosis and apnea is therefore the priority safety concern during this phase, because hypoxia can rapidly lead to cardiac compromise or brain injury if not recognized immediately. The nurse should be prepared to protect the airway and provide supplemental oxygen as needed once the tonic phase passes. Unilateral jerking of limbs is characteristic of focal motor or clonic seizures, not the tonic phase of a tonic-clonic seizure. Excessive drooling and lip-smacking are automatisms associated with focal temporal lobe seizures, which are a different seizure type altogether. Sudden loss of muscle tone and collapse describes an atonic, or drop, seizure, which is distinct from tonic-clonic activity. Since the question specifically asks about the tonic phase of a tonic-clonic seizure in this 7-year-old, monitoring for respiratory compromise manifested as cyanosis and apnea is the most clinically urgent priority.
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