A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

The correct answer is choice d. Measure the client’s abdominal girth daily.

Choice A rationale:

Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.

Choice B rationale:

Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.

Choice C rationale:

Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.

Choice D rationale:

Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.

Choice A reason:

Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.

Choice B reason:

Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.

Choice C reason:

Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.

Choice D reason:

Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity.