What is the priority nursing responsibility for a child experiencing a tonic-clonic seizure?

Protecting the child from self-injury during a tonic-clonic seizure is the priority nursing responsibility because these types of seizures involve both a tonic phase, where the muscles stiffen, and a clonic phase, characterized by rhythmic jerking movements. During these phases, the child is at a significant risk of harming themselves due to the loss of muscle control and consciousness.

By ensuring that the child is in a safe environment—removing dangerous objects, cushioning their head, and preventing them from falling or hitting hard surfaces—the nurse can mitigate the potential for injury. It is crucial to prioritize immediate safety, as injuries can occur quickly and may have serious consequences.

Other responsibilities, such as administering medication or calling for emergency medical assistance, may also be important, but they do not take precedence over the need to protect the child from harm during the seizure. Ensuring comfort is secondary to addressing immediate safety needs. The sequence of care during and after a seizure should focus first on preventing injury, followed by the administration of necessary medications, comfort, and seeking further medical assistance when needed.