A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply)

Choice A reason: Inserting a tongue depressor during a seizure is contraindicated as it risks oral injury, tooth damage, or airway obstruction. Seizures cause involuntary jaw clenching, and forcing objects into the mouth can lead to trauma, bleeding, or aspiration, exacerbating the situation and potentially causing respiratory compromise. Choice B reason: Restraining a client during a seizure can cause fractures or soft tissue injuries due to forceful muscle contractions. It may also increase agitation, complicating care. Allowing the seizure to occur while ensuring a safe environment minimizes harm and supports the natural resolution of seizure activity without physical restriction. Choice C reason: Assessing airway patency is essential during a seizure, as muscle rigidity and secretions can obstruct the airway, leading to hypoxia. Ensuring a clear airway maintains oxygenation and cerebral perfusion, preventing complications like brain damage from prolonged oxygen deprivation, making this a critical nursing intervention. Choice D reason: Removing objects from the bed prevents injuries from collisions during seizure-induced movements. This action ensures a safe environment, reducing the risk of trauma such as bruises or fractures, which could complicate recovery. It supports patient safety by minimizing external hazards during uncontrolled muscle activity. Choice E reason: Placing the client side-lying facilitates drainage of secretions, reducing aspiration risk. Seizures can impair airway clearance, and the lateral position uses gravity to keep the airway open, preventing hypoxia and pulmonary complications like aspiration pneumonia, which can be life-threatening if not managed promptly.