You are a nurse caring for a 10-year-old child diagnosed with Duchenne Muscular Dystrophy (DMD). The child is experiencing difficulty with walking and frequent falls.
What is the most appropriate nursing intervention to promote mobility and prevent falls for this patient?

Choice A rationale

Performing a fasciotomy is a surgical procedure, not an initial nursing intervention. While it may be necessary to relieve compartment syndrome, it is outside the scope of nursing practice and is typically performed by a physician. The nurse's role is to identify the signs and symptoms and escalate to the medical team for this definitive treatment.

Choice B rationale

Loosening the cast dressings or bandages directly addresses the potential cause of compartment syndrome by reducing external compression. This action aims to improve blood flow and nerve function by alleviating pressure on the neurovascular structures within the confined space. This can prevent further tissue ischemia and damage.

Choice C rationale

Elevating the affected limb above heart level can paradoxically worsen compartment syndrome. Elevation decreases arterial perfusion pressure, further compromising blood flow to the already ischemic tissues within the rigid fascial compartment. This can exacerbate tissue hypoxia and cellular damage, increasing the risk of irreversible injury.

Choice D rationale

Applying ice to the affected area causes vasoconstriction, which would further reduce blood flow to the compromised tissues within the compartment. This decrease in perfusion would exacerbate ischemia and hypoxia, potentially worsening tissue damage and accelerating the progression of compartment syndrome. Therefore, ice application is contraindicated.

Choice A rationale

Repositioning the client to a left lateral position aims to improve uteroplacental perfusion by alleviating compression of the inferior vena cava by the gravid uterus. This enhances venous return to the mother's heart, increasing cardiac output and ultimately improving blood flow and oxygen delivery to the placenta and fetus, which can resolve late decelerations caused by uteroplacental insufficiency.

Choice B rationale

Documenting findings is a crucial nursing responsibility, but it is not the immediate intervention for addressing late decelerations. Scientific principles dictate that physiological stabilization takes precedence over documentation when fetal well-being is compromised. Documentation would follow after initial interventions are implemented to improve the fetal status.

Choice C rationale

Adjusting fetal monitor sensors might be necessary if the tracing is poor quality, but it does not directly address the physiological cause of late decelerations. Late decelerations reflect uteroplacental insufficiency, not merely a monitoring artifact. Addressing the underlying physiological compromise is the priority before troubleshooting equipment.

Choice D rationale

Inserting a fetal scalp electrode provides a more accurate assessment of fetal heart rate by directly monitoring the fetus. However, this is an invasive procedure and is typically considered after initial conservative measures, such as maternal repositioning and oxygen administration, have been attempted without resolution of the late decelerations.