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 B

Explanation

A. Gathering supplies for an Intravenous (IV) infusion may be necessary if the infant becomes dehydrated or requires fluid resuscitation, but it is not the first action to take when there are concerns about a potential intestinal obstruction.

B. Measure abdominal circumference.

The infant's failure to pass meconium stool and the vomiting of bilious secretions are concerning signs that could indicate an obstruction in the gastrointestinal tract. Measuring the abdominal circumference is an essential initial assessment to determine if there is abdominal distension or enlargement, which can be a sign of an obstruction. Abdominal distention can help the healthcare provider assess the severity of the issue and make informed decisions regarding further diagnostic tests and interventions.

C. Preparing for anorectal manometry is not the first step in this situation. Anorectal manometry is a diagnostic test that may be considered later, depending on the findings and the healthcare provider's assessment.

D. Monitoring strict urinary output is not the primary concern in this case; the focus should be on assessing the infant's gastrointestinal status and potential bowel obstruction.

The nurse should promptly measure the infant's abdominal circumference to assess for signs of abdominal distension or obstruction and then communicate these findings to the healthcare provider for further evaluation and intervention.

A. Osteosarcoma. B. Rhabdomyolysis. C. Growing pains. D. Hemosiderosis.

Correct Answer is A

Explanation

A. Osteosarcoma.

The presentation of localized knee pain, especially when it worsens at night, along with swelling, tenderness, and the presence of radial ossification in the soft tissues, raises concerns about the possibility of osteosarcoma. Osteosarcoma is a malignant bone tumor that commonly occurs in the long bones of the body, such as the femur, and often presents with these clinical features.

B. Rhabdomyolysis is a condition that results from the breakdown of muscle tissue and typically presents with symptoms such as muscle pain, weakness, and dark urine due to the release of muscle proteins into the bloodstream. It is not the likely cause of the findings described.

C. Growing pains are typically characterized by intermittent, mild, and diffuse musculoskeletal pain and discomfort in children and adolescents. They do not typically involve localized knee pain, swelling, or tenderness.

D. Hemosiderosis refers to the accumulation of iron in the body and is not typically associated with the described findings or symptoms.

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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

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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