01
Febrile Seizures
Most common seizure type in children — usually benign, but terrifying for parents.
- Age: 6 months – 5 years
- Cause: rapid rise in temperature (not the height of fever — the rate of rise)
- Typically brief (<15 min), generalized tonic-clonic
- Most children have no lasting neurological effects
Nursing Actions During a Febrile Seizure
1
Do NOT restrain — protect from injury only (clear the area, side-lying position).
2
Time the seizure — report if >5 minutes.
3
Do NOT put anything in the child's mouth.
4
Position: side-lying (prevents aspiration of secretions).
5
After seizure: administer antipyretic (acetaminophen or ibuprofen), reassess.
6
Notify provider — first febrile seizure requires evaluation.
Parent Teaching
- Very common — occurs in 2–5% of children
- Does NOT mean child will develop epilepsy (slightly increased risk, but still small)
- Teach to protect child, call 911 if >5 min, bring to ED after first febrile seizure
- Reduce fever with antipyretics — but this does NOT guarantee seizure prevention
Exam Tip
Priority during seizure = airway and safety. Never restrain. Position on side. The most common NCLEX mistake is choosing an intervention that involves putting something in the child's mouth — this is always wrong. After the seizure, the child will have a postictal phase (confusion, sleepiness) — this is normal.
? A child is having a febrile seizure. What are the priority nursing actions in order?
(1) Do NOT restrain — protect from injury (clear area). (2) Position side-lying. (3) Do NOT put anything in the mouth. (4) Time the seizure. (5) After seizure ends: give antipyretic, notify provider. Do NOT give oral medication during an active seizure — airway and safety come first. If the seizure lasts about 5 minutes or rescue medication is ordered, give a benzodiazepine per protocol.
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02
Foreign Body Aspiration
A leading cause of accidental death in children under 4 — hot dogs, grapes, nuts, and coins are top offenders.
Signs and Symptoms
- Sudden onset of coughing, choking, gagging while eating or playing
- Stridor (upper airway) or unilateral wheezing (lower airway)
- Cyanosis if complete obstruction
- Child may become suddenly quiet (complete obstruction — no air moving)
Nursing Actions by Severity
- Partial obstructioncan cough/speak/cry
- Encourage forceful coughing. Do NOT intervene — coughing is most effective. Stay with child, call for help.
- Complete obstructioncan't cough/speak/breathe
- Infant (<1 yr): 5 back blows + 5 chest thrusts. Child (>1 yr): Heimlich maneuver (abdominal thrusts). Call 911.
- Unconsciousno response
- Start CPR. Look in mouth before giving breaths — only remove object if you can SEE it (never blind finger sweep).
Infant vs Child Technique
For infants under 1 year: back blows to chest thrusts — NOT abdominal thrusts (risk of liver injury). Position infant face-down on forearm, deliver 5 firm back blows between shoulder blades, then flip and give 5 chest thrusts. This distinction is always tested.
Prevention Teaching
- Cut food into small pieces (smaller than 1/2 inch for children under 4)
- No round, firm foods: whole grapes, hot dogs, hard candy, popcorn, nuts, raw carrots
- Supervise all meals
- Keep small objects away from children under 3 (toy parts, coins, batteries)
03
Pediatric Meningitis
Inflammation of the meninges — bacterial meningitis is a life-threatening emergency.
Classic Triad (older children)
- Fever (high, sudden)
- Severe headache
- Stiff neck (nuchal rigidity)
Signs in Infants (classic triad may be absent)
- Bulging fontanel — hallmark in infants
- High-pitched cry ("meningeal cry")
- Fever or hypothermia (in preterm/newborns)
- Poor feeding, irritability when handled (hyperesthesia)
- Photophobia, seizures
Meningeal Signs
- Brudzinski's sign
- Flex the neck → hips and knees flex involuntarily (positive = meningitis).
- Kernig's sign
- Flex hip 90 deg → unable to extend knee without pain (positive = meningitis).
- Petechial/purpuric rash
- Non-blanching — associated with meningococcal meningitis — septicemia/DIC.
Nursing Care
- Droplet precautions immediately (bacterial meningitis)
- IV antibiotics ASAP — do NOT delay for LP results if child is deteriorating
- Dim lights, quiet room (photophobia and noise sensitivity)
- HOB elevated 30 degrees (reduces ICP)
- Monitor neuro status q1–2h (ICP changes rapidly)
- Monitor for SIADH (fluid restriction may be ordered)
Non-Blanching Rash = Emergency
A petechial or purpuric (non-blanching) rash with fever = meningococcal septicemia until proven otherwise. Press a glass on the rash — if it does NOT fade = non-blanching. This is a medical emergency with a very high mortality rate if not treated immediately.
04
Child Abuse Recognition
Nurses are mandatory reporters — suspicion alone requires reporting. You do not need proof.
Physical Abuse Red Flags
- Bruises in unusual locations: ears, neck, buttocks, back, torso (accidental bruises usually on shins, knees, forehead)
- Bruises in various stages of healing (different colors = different ages of injury)
- Patterned injuries: belt buckle marks, cigarette burns, cord marks
- Fractures inconsistent with developmental stage: femur fracture in non-walking infant
- Bilateral black eyes without head trauma mechanism
- Delay in seeking care or changing stories between caregivers
Shaken Baby Syndrome (Abusive Head Trauma)
- Violent shaking causes: subdural hematoma, retinal hemorrhages, diffuse axonal injury
- Infant may present with: lethargy, seizures, vomiting, bulging fontanel, no external marks
- Classic: no external signs of trauma but severe neurological symptoms
Nursing Role
- Document objectively — describe injuries exactly, use body map diagrams, note exact words of caregivers
- Interview child separately from caregivers when developmentally appropriate
- Mandatory reporter — report suspicion to CPS (Child Protective Services). You do NOT confront the abuser.
- Do NOT promise the child confidentiality
- Ensure child's immediate safety
Key Legal Point
Mandatory reporting protects the nurse from liability — as long as the report is made in good faith. You can be held legally liable for NOT reporting suspected abuse. When in doubt, report.
05
Pediatric CPR Differences
Pediatric CPR follows the same CAB sequence as adults but with key differences in technique and ratios.
- Pulse check siteinfant · child · adult
- Brachial artery (inner upper arm) · Carotid artery · Carotid artery
- Compression siteinfant · child · adult
- 2 fingers, center of chest, just below nipple line · Heel of one or two hands, lower half of sternum · Two hands, lower half of sternum
- Compression depthinfant · child · adult
- 1.5 inches (4 cm) · 2 inches (5 cm) · 2–2.4 inches
- Compression:breath ratioinfant · child · adult
- 30:2 (1 rescuer), 15:2 (2 rescuers) · 30:2 (1 rescuer), 15:2 (2 rescuers) · 30:2
- Breathsinfant · child · adult
- Mouth-to-mouth-and-nose · Mouth-to-mouth · Mouth-to-mouth
- Defibrillationinfant/child · adult
- Pediatric pads if available. 2 J/kg first shock. · Adult pads. 200J biphasic.
Key Differences to Remember
Brachial pulse in infants (not carotid — neck too short and fat). Two-thumb encircling technique preferred for infant compressions with 2 rescuers. Pediatric 2-rescuer ratio is 15:2 (not 30:2 like adults). Children are more likely to arrest from respiratory failure than cardiac causes — airway is always the priority.
06
Pediatric Shock
Children compensate extremely well — by the time BP drops, the child is in decompensated shock.
- Early (compensated) shock: tachycardia, normal BP, pallor, cool extremities, delayed cap refill (>2 sec)
- Late (decompensated) shock: hypotension, altered LOC, mottling, absent peripheral pulses, oliguria
- Tachycardia is the first and most sensitive sign of shock in children
Fluid Resuscitation
- Normal saline (NS): 20 mL/kg IV bolus — can repeat up to 3 times
- Reassess after each bolus: HR, BP, cap refill, urine output
- Urine output goal: 1 mL/kg/hr in children (vs 0.5 mL/kg/hr in adults)
? A 3-year-old has a heart rate of 160 bpm but normal blood pressure after a fall. Why is tachycardia the priority concern?
In children, tachycardia is the first and most sensitive sign of shock — they maintain blood pressure through compensatory vasoconstriction until decompensation is well advanced. Do not wait for hypotension to treat. Treat this as early (compensated) shock: assess cap refill, urine output, and mental status; prepare NS 20 mL/kg IV bolus.
07
Frequently Asked Questions
Common student questions on this topic.
How is pediatric CPR different from adult CPR?
Key differences: Compression ratio: 30:2 (one rescuer) or 15:2 (two rescuers for child/infant). Compression depth: 2 inches in adults, about 2 inches in children, 1.5 inches in infants. Compression site: lower half of sternum in adults/children, just below the nipple line (or 2 fingers below) in infants. Compression technique: 2 hands (adult/child), 2 fingers (infant, single rescuer), 2 thumbs encircling (infant, two rescuers). Pulse check: carotid (adult/child), brachial (infant).
What is the priority assessment for a child who has been in a near-drowning event?
Priorities follow ABCs. Airway and breathing first — assess for respiratory distress, hypoxia. Even children who appear well after immersion need observation because of risk of secondary drowning (delayed pulmonary edema up to 24 hours later). Hypothermia is common — warm gradually. C-spine precautions if diving was involved or trauma suspected. Aggressive resuscitation can have good outcomes due to the mammalian dive reflex, especially in cold water.
How do I recognize signs of child abuse?
Watch for: injuries inconsistent with the reported mechanism, multiple injuries in different stages of healing, injuries in unusual locations (back, buttocks, ears, abdomen), burn patterns (cigarette burns, glove/stocking immersion burns), delay in seeking care, parent-child interaction concerns (overly compliant, fearful, withdrawn), and inconsistent histories. Nurses are mandatory reporters — must report suspected abuse to child protective services. Document objectively without accusations.
What are the priority interventions for a febrile seizure?
Febrile seizures occur with a rapidly rising fever, typically in children 6 months to 5 years. Most are brief and benign. (1) Protect the airway — turn the child on their side, do not put anything in the mouth. (2) Time the seizure. (3) After it ends, give acetaminophen or ibuprofen for fever (sometimes by rectal route if drowsy). (4) Find the source of fever. (5) Reassure parents — most children outgrow them by age 5 and don't develop epilepsy.
What should I do if a child is choking?
If the child is coughing or speaking: encourage them to cough — do not interfere. If unable to cough/cry/speak: For infants < 1 year: 5 back blows, then 5 chest thrusts, alternate until object is expelled or infant becomes unresponsive. For children ≥ 1 year: abdominal thrusts (Heimlich). If unresponsive: begin CPR, check the mouth for visible object before giving breaths (do NOT blind-finger sweep). Call 911.
What are the signs of pediatric shock?
Children compensate longer than adults — by the time blood pressure drops, the child is already in decompensated shock. Earlier signs: tachycardia, weak peripheral pulses, prolonged capillary refill (> 2 seconds), cool extremities, altered mental status (irritability or lethargy), decreased urine output. Hypotension is a late sign in children. Treat shock aggressively with isotonic IV fluid boluses (20 mL/kg), reassess, repeat as needed. Identify and treat the underlying cause.
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