When providing care for a child who is 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?

Cleanse pin sites as prescribed.

Monitor peripheral pulses and sensation in the right leg.

Assess skin for redness and signs of tissue breakdown.

Change position every 2 hours.

Answer and Explanation

The Correct Answer is B

A. Cleansing pin sites as prescribed is important for infection prevention, but it is not the most critical intervention in the context of assessing vascular and neurologic status.

B. Monitor peripheral pulses and sensation in the right leg.

Balanced suspension skeletal traction is used to stabilize fractures or treat certain orthopedic conditions. Monitoring peripheral pulses and sensation in the right leg is a critical aspect of caring for a child in this type of traction. It is essential to ensure that the child's circulation and nerve function are not compromised. 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.

C. 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 sensation when the child is in traction.

D. 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.

Peripheral pulses and sensation must be closely monitored and documented at regular intervals to ensure the child's safety and the effectiveness of the traction. Any changes in these parameters should be promptly reported to the healthcare provider.

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Correct Answer is C

Explanation

A. Ensure placement of the enteral tube with an abdominal x-ray:Verifying enteral tube placement is essential for safety, but it is not related to maintaining the newborn's growth and development. Tube placement should already have been verified prior to initiating feedings.

B. Speak to the healthcare provider about instituting physical therapy:Physical therapy may be beneficial for infants with specific motor delays, but it is not a routine intervention for all infants recovering from gastroschisis.

C. Offer a pacifier for non-nutritive sucking:Non-nutritive sucking (e.g., using a pacifier) is crucial for the growth and development of newborns, especially those unable to feed orally. It helps promote oral-motor development, soothes the infant, and lays the foundation for transitioning to oral feeding. This is particularly important for an infant receiving parenteral or enteral nutrition to ensure they develop the skills and comfort needed for future oral feeding.

D. Use sterile technique during feedings:Clean technique is generally sufficientor routine enteral feedings unless there is a specific indication for sterility (e.g., immunocompromised clients). Further, this does not directly support growth and development.

A. Document the client's relief of pain. B. Inquire about the client's last meal. C. Give prescribed intravenous antibiotics. D. Contact the healthcare provider.

Correct Answer is D

Explanation

A. Documenting the client's relief of pain is important for the medical record but is not the first priority in this situation. The immediate concern is to determine the cause of the sudden pain relief and ensure the child's well-being.

B. Inquiring about the client's last meal is important for pre-operative considerations, but it is not the first action to take when sudden relief of abdominal pain is reported.

C. Giving prescribed intravenous antibiotics may be part of the treatment plan, but it should not be the first action when the child experiences sudden relief of abdominal pain. Contacting the healthcare provider to assess the situation is more urgent.

D Contact the healthcare provider.

In the case of a child diagnosed with appendicitis, sudden relief in abdominal pain can be concerning. This might indicate that the appendix has ruptured, leading to the spread of infection into the abdominal cavity, which can be a critical situation. It's essential for the healthcare provider to be informed immediately so they can assess the child's condition, order any necessary interventions, and potentially expedite the surgical procedure if required.

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When providing care for a child who is 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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A 9-year-old admitted to the unit with severe abdominal pain and fever is diagnosed with appendicitis and is placed on the surgery schedule for an appendectomy. The child reports to the nurse of experiencing sudden relief in abdominal pain. Which action should the nurse take first?

Correct Answer is D

Explanation

The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic antiinfective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?

The nurse is assessing a child with acute glomerulonephritis who presents to the clinic with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

When providing care for a child who is 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?

An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?

Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.