A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be preformed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

Notify the health care provider (HCP)

Administer an analgesic

Release the skin traction

Apply ice to the extremity

Answer and Explanation

The Correct Answer is A

A. The absence of the dorsalis pedis pulse in the right foot is concerning and could indicate compromised circulation to the extremity. It is essential to notify the healthcare provider promptly so that further assessment and intervention can be initiated to address the circulation issue and prevent potential complications such as ischemia or tissue damage.

B. Administering an analgesic may be necessary to manage the child's pain, especially if they are experiencing discomfort due to the femur fracture. However, addressing the absent dorsalis pedis pulse takes priority as it suggests a potential vascular problem that requires immediate attention.

C. Releasing the skin traction may not be appropriate at this point without further assessment and guidance from the healthcare provider. Skin traction is often used to temporarily stabilize fractures and reduce pain, and releasing it without proper evaluation could potentially exacerbate the injury or compromise the child's comfort and stability.

D. Applying ice to the extremity is not indicated in this situation. Ice application is typically used for acute injuries to reduce swelling and inflammation, but it is not appropriate when there is concern about compromised circulation.

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Correct Answer is ["A","D","E"]

Explanation

A. Decreased cardiac output in heart failure can lead to poor perfusion of the extremities, resulting in cool skin and decreased urine output due to reduced renal perfusion and impaired kidney function.

D. Poor feeding is often observed due to increased respiratory effort, tachypnea, and fatigue associated with heart failure. Additionally, infants may exhibit failure to thrive or inadequate weight gain despite increased caloric intake due to metabolic demands and inefficient utilization of nutrients.

E. Tachypnea and respiratory distress occur due to pulmonary congestion and increased respiratory effort in response to heart failure. Infants may exhibit signs such as nasal flaring, grunting, retractions, and cyanosis.

B. Bradycardia and hypotension are not typical manifestations of heart failure in infants. Instead, infants with heart failure often present with tachycardia (rapid heart rate) as a compensatory mechanism to maintain cardiac output. Hypotension may occur in severe cases but is not a common finding.

C. Increased appetite and excessive weight gain are not typical manifestations of heart failure in infants. Infants with heart failure often experience poor feeding and failure to thrive due to inadequate cardiac output and oxygen delivery to meet metabolic demands.

A. Constipation B. Depressed anterior fontanel C. Presence of the rooting reflex D. High-pitched cry

Correct Answer is D

Explanation

D. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.

A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.

B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.

C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).

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A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be preformed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are common manifestations of heart failure in infants? (SELECT ALL THAT APPLY)

Correct Answer is ["A","D","E"]

Explanation

A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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