When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

Monitor peripheral pulses and sensation in the right leg

Cleanse pin sites as prescribed

Check skin for redness and signs of tissue breakdown

Reposition the child every 2 hours

Answer and Explanation

The Correct Answer is A

Choice A rationale
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the right leg. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
Choice B rationale
While cleansing pin sites as prescribed is important for infection prevention, it is not the most critical intervention in the context of assessing vascular and neurologic status.
Choice C rationale
Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensations when the child is in traction.
Choice D rationale
Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.

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Correct Answer is A

Explanation

= Answer is... Choice A. Severe skin breakdown in the diaper area.

Choice A rationale:

In the case of the 3-month-old infant presenting with difficulty sleeping through the night, severe skin breakdown in the diaper area is the most significant finding requiring attention in care planning for this family. Diaper dermatitis, characterized by erythema, edema, and erosion of the skin in the diaper region, can cause considerable discomfort and distress to the infant. Moreover, severe skin breakdown increases the risk of secondary infections and exacerbates the infant's discomfort, potentially impacting sleep patterns and overall well-being.

Diaper dermatitis often results from prolonged exposure to urine and feces, friction, and the occlusive environment created by diapers. The acidic pH of urine and feces, coupled with the breakdown of urea into ammonia, contributes to skin irritation and inflammation. Additionally, the warm, moist environment beneath the diaper provides an ideal breeding ground for microbial overgrowth, further exacerbating skin damage.

Management of severe diaper dermatitis involves a multifaceted approach, including frequent diaper changes, gentle cleansing of the affected area, application of barrier creams or ointments, and promotion of air exposure to facilitate healing. In severe cases, topical corticosteroids or antifungal agents may be prescribed to reduce inflammation and prevent secondary infections.

Preventing and managing diaper dermatitis is essential not only for alleviating the infant's discomfort but also for promoting uninterrupted sleep patterns. Discomfort associated with diaper rash can lead to increased irritability and difficulty settling down for sleep, contributing to sleep disturbances for both the infant and the caregiver. By addressing the underlying cause of the skin breakdown and implementing appropriate interventions, healthcare providers can support the family in improving the infant's comfort and sleep quality.

Choice B rationale:

The mother stating that the baby is irritable during feedings is indeed noteworthy and may indicate various underlying issues, such as feeding difficulties, gastrointestinal discomfort, or inadequate milk supply. However, while irritability during feedings can contribute to disrupted sleep patterns, it is not as directly relevant to the immediate concern of severe skin breakdown in the diaper area. Nonetheless, addressing feeding concerns is essential for optimizing the infant's nutritional intake and overall well-being.

Choice C rationale:

The mother being a single parent and living with her parents provides contextual information about the family's social support structure but is not directly related to the infant's difficulty sleeping through the night or the significant finding of severe skin breakdown in the diaper area. While family dynamics and support systems play a crucial role in caregiving and may influence the implementation of care strategies, they do not directly address the infant's current health issue.

Choice D rationale:

The fact that the infant's formula has been changed twice may indicate attempts to address feeding-related concerns or suspected formula intolerance. While changes in formula may impact the infant's gastrointestinal comfort and feeding patterns, they do not directly address the primary concern of severe skin breakdown in the diaper area. Nonetheless, evaluating the appropriateness of the current formula and addressing any feeding-related issues remain important aspects of comprehensive care for the infant.

A. Obtain the essential information as quickly as possible. B. Include the child’s toy in the collection of information. C. Document interactions between the parent and the child. D. Ignore the child’s behavior, directing Questions to a parent.

Correct Answer is B

Explanation

Choice A rationale
While it’s important to obtain essential information as quickly as possible, this approach may not be the most effective when a child is scared or upset. It’s important to create a safe and comfortable environment for the child.
Choice B rationale
Including the child’s toy in the collection of information can help to create a more familiar and comfortable environment for the child. This can help to reduce fear and anxiety, making it easier to collect the necessary information.
Choice C rationale
Documenting interactions between the parent and the child can provide valuable information about the child’s behavior and emotional state. However, this is not the most effective intervention in this situation.
Choice D rationale
Ignoring the child’s behavior and directing questions to a parent can make the child feel overlooked and may increase their fear and anxiety. It’s important to acknowledge the child’s feelings and work to create a safe and comfortable environment.

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When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

Correct Answer is A

Explanation

The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. What intervention should the nurse implement?

Correct Answer is B

Explanation

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