A nurse is caring for a toddler who has a fractured right femur and is in Bryant traction. When determining that the traction is appropriately assembled, the nurse should observe which of the following?

Choice A reason: A respiratory rate of 24 breaths/min is within the normal range for a 3-year-old child. It does not indicate the degree of hydration or dehydration of the child.

Choice B reason: A heart rate of 130/min is above the normal range for a 3-year-old child, which is 80 to 120/min. It may indicate dehydration, fever, pain, or anxiety. It does not indicate the effectiveness of oral rehydration therapy.

Choice C reason: A urine specific gravity of 1.015 is within the normal range for a child, which is 1.005 to 1.030. It indicates that the child's urine is adequately concentrated and that the child is well hydrated. It is a reliable indicator of the effectiveness of oral rehydration therapy.

Choice D reason: A capillary refill of greater than 3 seconds is abnormal and indicates poor peripheral perfusion. It may be a sign of dehydration, shock, or hypothermia. It does not indicate the effectiveness of oral rehydration therapy.

Choice A reason: Meningitis is a possible condition, as it is an inflammation of the membranes that cover the brain and spinal cord. It can be caused by various microorganisms, such as bacteria, viruses, or fungi. The infant has many signs and symptoms of meningitis, such as fever, irritability, lethargy, bulging fontanel, and clear cerebrospinal fluid from the lumbar puncture.

Choice B reason: Hydrocephalus is not a likely condition, as it is an accumulation of cerebrospinal fluid in the brain, which causes increased intracranial pressure and enlargement of the head. The infant has a bulging fontanel, which can indicate increased intracranial pressure, but not necessarily hydrocephalus. The infant does not have other signs of hydrocephalus, such as a rapidly increasing head circumference, prominent scalp veins, or sunset eyes.

Choice C reason: Intracranial hemorrhage is not a probable condition, as it is a bleeding within the skull, which can result from trauma, vascular malformation, or coagulation disorder. The infant has retinal hemorrhages, which can indicate intracranial hemorrhage, but not necessarily. The infant does not have other signs of intracranial hemorrhage, such as seizures, vomiting, or altered mental status.

Choice D reason: Sepsis is not a definite condition, as it is a systemic inflammatory response to an infection, which can cause organ dysfunction and shock. The infant has a fever, which can indicate sepsis, but not necessarily. The infant does not have other signs of sepsis, such as tachycardia, tachypnea, hypotension, or poor perfusion.