When providing care 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?
Change position every 2 hours.
Monitor peripheral pulses and sensation in the right leg.
Cleanse pin sites as prescribed.
Assess skin for redness and signs of tissue breakdown.
The Correct Answer is B
When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the affected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.
Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.
Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The startle reflex, also known as the Moro reflex, is a normal reflex in infants that is present at birth and usually disappears by 3-4 months of age. The reflex is elicited by a sudden loud noise or change in position, and the infant will extend their arms and legs, then bring them back in towards their body.
If a 6-month-old infant is still demonstrating the startle reflex, it may indicate a developmental delay or neurological issue and requires further evaluation by the nurse or healthcare provider.
The other responses are all normal developmental milestones for a 6-month-old infant. By 6 months of age, most infants will have doubled their birth weight, enjoy playing games like peek-a-boo, and have developed the ability to turn their head to locate sounds.
Correct Answer is D
Explanation
Aortic stenosis is a narrowing of the aortic valve, which can cause decreased blood flow from the left ventricle to the systemic circulation. In infants with aortic stenosis, the left ventricle must work harder to pump blood through the narrowed valve, which can lead to left ventricular hypertrophy, heart failure, and pulmonary edema. Bilateral fine crackles in both lung fields may indicate fluid overload in the lungs, which is a common complication of heart failure. Hypotension and tachycardia may also be present due to decreased cardiac output.
Option A is not a typical finding associated with aortic stenosis.
Option B is not directly related to the infant's cardiac condition.
Option C is not a typical finding associated with heart failure.
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