Exhibits

Review H and P, and nurse's note.

Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.

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.

• Ask the healthcare provider to prescribe a nonsteroidal anti-inflammatory drug (NSAID)
  NSAIDs such as ibuprofen are commonly used for postoperative pain relief in infants. They provide anti-inflammatory effects and pain control without the risk of respiratory depression seen with opioids. Given the infant’s surgical status, an NSAID can be an effective pain management option when prescribed appropriately.
• Have one of the parents hold the baby: Parental presence and skin-to-skin contact are effective non-pharmacologic pain management strategies for infants. Holding and gentle rocking can provide comfort, reduce stress, and help lower the infant’s FLACC score by promoting relaxation.
• Perform guided imagery: Guided imagery requires cognitive maturity, which a 4-month-old infant lacks. This technique is more appropriate for older children who can understand and visualize calming scenes. For infants, tactile and auditory comfort measures (such as holding and swaddling) are more effective.
• Consult a child life specialist: A child life specialist can assist in non-pharmacologic pain management strategies, such as age-appropriate distraction techniques, comfort positioning, and soothing interventions. While the infant may not engage in interactive play, the specialist can help guide parents in comforting their baby.
• Encourage the baby's mother to breastfeed the baby: The infant is NPO (nothing by mouth) postoperatively, meaning breastfeeding is contraindicated at this time. Providing oral intake against medical orders could lead to complications, especially after fundoplication surgery, which affects gastric emptying.
• Wait 1 hour, reassess, and give medication if the FLACC score remains elevated: Delaying pain relief for an infant experiencing postoperative pain is not appropriate. Infants cannot verbalize pain, and an elevated FLACC score indicates discomfort. Instead of waiting, the nurse should take immediate action by implementing comfort measures and/or requesting appropriate pain medication.
• Request a prescription for an opioid: If the infant's pain is moderate to severe, an opioid (such as morphine) may be needed for adequate pain relief. Opioids are used cautiously in infants due to the risk of respiratory depression, but they are appropriate for postoperative pain control when NSAIDs alone are insufficient.