Exhibits

Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.

A. Avoid any smoking inside the house. Exposure to secondhand smoke increases the risk of recurrent otitis media by irritating the respiratory tract and impairing mucociliary clearance. Reducing or eliminating smoke exposure is an essential preventive measure to lower inflammation and decrease bacterial colonization in the middle ear.
B. Give infant the full course of antibiotics. Completing the full course of prescribed antibiotics ensures that the infection is fully treated, preventing bacterial resistance and reducing the likelihood of recurrent or persistent infections. Stopping antibiotics prematurely can lead to incomplete eradication of the bacteria and increase the risk of future infections.
C. Schedule visit for pneumococcal vaccine. The pneumococcal vaccine protects against Streptococcus pneumoniae, one of the leading causes of otitis media. Ensuring that the infant is up to date with routine vaccinations, including the pneumococcal and Haemophilus influenzae type B (Hib) vaccines, can significantly reduce the risk of recurrent infections.
D. Instill benzocaine otic drops regularly. Benzocaine otic drops provide temporary pain relief but do not prevent or treat infections. Using them regularly without medical guidance may mask symptoms of worsening infection, delay appropriate treatment, or cause local irritation. Pain management should be used only as needed and in conjunction with appropriate medical interventions.

A. Palpate femoral pulses. While assessing pulses is important in circulation checks, femoral pulses are located proximally and may not accurately reflect distal circulation in the casted limb. Checking pulses in the lower extremities, such as the dorsalis pedis or posterior tibial pulses, would be more relevant.
B. Compare temperature of both legs. Temperature comparison can help detect circulatory compromise, but it is a less immediate and less specific indicator than capillary refill. A leg may feel cool due to prolonged exposure rather than poor perfusion, making capillary refill a more reliable assessment.
C. Monitor capillary refill of the toes. Capillary refill is a critical assessment for adequate circulation in a child with a cast. Delayed capillary refill (greater than 2 seconds) may indicate compromised blood flow, which could result from excessive cast tightness or compartment syndrome, requiring immediate intervention.
D. Examine for spontaneous movement. Assessing movement is important in evaluating nerve function, but it does not directly assess vascular compromise, which is the most immediate concern in a newly applied cast. Lack of movement could indicate nerve damage but is not the primary priority over circulation assessment.