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Which of the following actions should the nurse take when caring for a child in skeletal traction? (Select All that Apply)

Encourage the child to bear weight on the affected limb

Remove the traction periodically to allow the child to take a break

Encourage the child to move the affected limb frequently

Encourage the child to participate in physical activities to promote mobility

Assess the child's neurovascular status regularly

Monitor for signs of infection at the traction site

Administer pain medication as needed

Apply ice packs to the traction site to reduce swelling

Answer and Explanation

Correct Answer : E,F,G

A. Bearing weight on the affected limb is contraindicated in skeletal traction.

B. Traction should not be removed unless directed by the provider, as it could compromise the treatment.

C. Movement of the affected limb is generally restricted to prevent disrupting alignment.

D. Physical activity should be limited to prevent stress on the traction apparatus.

E. Regular neurovascular assessments help identify complications like compartment syndrome.

F. Monitoring for infection is essential due to the invasive nature of skeletal traction.

G. Pain management is important for patient comfort.

H. Ice is generally not applied directly to traction sites; instead, the nurse monitors for complications.

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Correct Answer is A

Explanation

A. A neurovascular assessment is priority to ensure circulation is adequate in the affected limb, preventing complications like compartment syndrome.

B. Ice application can help reduce swelling but is secondary to ensuring circulation.

C. Providing reassurance is supportive but not as critical as physical assessment.

D. Discharge instructions are important but can follow the neurovascular assessment.

A. Stabilize the infant's spine. B. Palpate fontanel level. C. Assess pupillary reaction to light. D. Encourage the guardian to feed the infant. E. Measure the infant's head circumference. F. Evaluate for the presence of a Babinski reflex

Correct Answer is ["A","B","C","E"]

Explanation

A. This is crucial due to the potential for a spinal injury given the mechanism of the fall. Stabilizing the spine can help prevent further injury while the infant is being assessed.

B. Monitoring the fontanel is important to assess for increased intracranial pressure. The anterior fontanel should be flat and level; bulging could indicate swelling or pressure.

C. This is vital for evaluating neurological status and determining if there are any signs of increased intracranial pressure or brain injury.

D. This is not appropriate at this time, as the infant is difficult to awaken, which could indicate a risk for aspiration.

E. Measuring head circumference can help track changes and monitor for signs of increased intracranial pressure or other complications.

F. While assessing reflexes may provide information on neurological function, it is not the priority compared to the other actions listed.

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Which of the following actions should the nurse take when caring for a child in skeletal traction? (Select All that Apply)

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