Following a tonic-clonic seizure, what is the first action a school nurse should take?

Following a tonic-clonic seizure, what is the first action a school nurse should take?

• A. Check the child for a head injury
• B. Observe for oral bleeding
• C. Check the child's respiratory rate
• D. Observe for extremity weakness

Answer: (C)

The first action a school nurse should take following a tonic-clonic seizure is to check the child's respiratory rate. This is crucial because during a seizure, especially a tonic-clonic seizure, the child may experience alterations in airway patency due to muscle contractions, potential oral injury, or even temporarily cease breathing. Monitoring the respiratory rate allows the nurse to assess the child's airway status and ensure that they are breathing adequately after the seizure has ended. Ensuring proper ventilation and oxygenation is essential to provide appropriate first aid and to prevent complications such as hypoxia. In this context, checking for head injuries may be important, but it typically follows assessing the child's immediate emergency needs like breathing. Observing for oral bleeding is also relevant, especially if there was any biting of the tongue, but since respiratory issues can pose an immediate threat to life, assessing the respiratory rate should take precedence. Observing for extremity weakness can be necessary afterward, especially to evaluate postictal status, but it is essential to prioritize the child’s airway and breathing first.

The first action a school nurse should take following a tonic-clonic seizure is to check the child's respiratory rate. This is crucial because during a seizure, especially a tonic-clonic seizure, the child may experience alterations in airway patency due to muscle contractions, potential oral injury, or even temporarily cease breathing. Monitoring the respiratory rate allows the nurse to assess the child's airway status and ensure that they are breathing adequately after the seizure has ended. Ensuring proper ventilation and oxygenation is essential to provide appropriate first aid and to prevent complications such as hypoxia.

In this context, checking for head injuries may be important, but it typically follows assessing the child's immediate emergency needs like breathing. Observing for oral bleeding is also relevant, especially if there was any biting of the tongue, but since respiratory issues can pose an immediate threat to life, assessing the respiratory rate should take precedence. Observing for extremity weakness can be necessary afterward, especially to evaluate postictal status, but it is essential to prioritize the child’s airway and breathing first.