A mother brings her preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

Choice A reason: Obtaining a 12-lead electrocardiogram is not the first intervention that the nurse should implement. An electrocardiogram is a test that measures the electrical activity of the heart and can detect abnormalities in the heart rhythm or structure. However, it is not a priority for an infant who has already had surgical correction for TOF and is not showing signs of distress.

Choice B reason: Stimulating the infant to cry to produce cyanosis is not an intervention that the nurse should implement at all. Cyanosis is a bluish discoloration of the skin due to low oxygen levels in the blood. It is a common symptom of TOF and can be triggered by crying or other stressors. However, it is not a desirable outcome and can cause harm to the infant. The nurse should avoid provoking cyanosis and instead provide comfort and oxygen to the infant.

Choice C reason: Auscultating heart and lungs while the infant is held is the first intervention that the nurse should implement. This is a simple and noninvasive way to assess the infant's respiratory and cardiac status. The nurse can listen for any abnormal sounds, such as crackles, wheezes, or murmurs, that may indicate a problem. The nurse can also monitor the infant's heart rate and oxygen saturation. Holding the infant can provide comfort and security to the infant and the mother.

Choice D reason: Evaluating the infant for failure to thrive (FTT) is not the first intervention that the nurse should implement. FTT is a condition where an infant does not grow or gain weight as expected. It can be caused by various factors, such as inadequate nutrition, chronic illness, or psychosocial issues. However, the infant in this scenario is not showing signs of FTT, as his growth is in the expected range. The nurse should focus on the infant's current symptoms and needs.

Choice A reason: Changing position every 2 hours is not the most important intervention that the nurse should implement. This is because the child's position is limited by the traction and the splint, and frequent repositioning may interfere with the alignment and stability of the fracture. The nurse should only change the position of the child as ordered by the physician and with the assistance of another nurse.

Choice B reason: Assessing skin for redness and signs of tissue breakdown is not the most important intervention that the nurse should implement. This is because the skin is not directly in contact with the traction or the splint, and the risk of pressure ulcers is low. The nurse should still inspect the skin regularly and provide skin care as needed, but this is not the priority.

Choice C reason: Cleansing pin sites as prescribed is not the most important intervention that the nurse should implement. This is because the pin sites are not the main source of infection or complication in this type of traction. The nurse should still follow the protocol for pin site care and monitor for signs of infection, such as redness, swelling, drainage, or odor, but this is not the priority.

Choice D reason: Monitoring peripheral pulses and sensation in the right leg is the most important intervention that the nurse should implement. This is because the traction and the splint can impair the circulation and nerve function of the affected extremity, leading to complications such as compartment syndrome, ischemia, or nerve damage. The nurse should check the pulses, temperature, color, capillary refill, and sensation of the right leg at least every hour and report any changes or abnormalities to the physician.