The practical nurse (PN) is monitoring a 5-year-old following a fracture of the ulna. For which situation should the PN seek immediate intervention by the registered nurse (RN)?
The child likes to wiggle the fingers on the hand of the affected side.
The child's radial pulse volume on the affected arm is difficult to palpate.
An accurate respiratory rate cannot be measured because of the child's crying.
The parents of the child are requesting that the child receive an analgesic.
The Correct Answer is B
This could indicate reduced blood flow to the affected arm, which may be a sign of compartment syndrome. Compartment syndrome is a serious condition that requires immediate intervention by a registered nurse (RN). The other options may also require intervention, but they are not as urgent as the situation described in option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When a Rh-negative mother gives birth to a Rh-positive baby, there is a risk that the mother's immune system will develop antibodies against the Rh-positive factor. These antibodies can cross the placenta in future pregnancies and atack the Rh-positive fetus, leading to hemolytic disease of the newborn. Rho(D) immune globulin is given after delivery to prevent the formation of these antibodies. The PN should explain this to the client and encourage her to reconsider her refusal of the treatment. Answers A, B, and C are incorrect and do not provide accurate information.
Correct Answer is D
Explanation
An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.
Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.
Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.
Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.
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