A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down.

Which action(s) should the nurse take? Select all that apply.

A. Place pillows inside the side rails.

Choice A rationale

Comparing the temperature of both legs can help identify potential circulatory issues or infections. However, temperature differences are not the most immediate concern when assessing a child with a long-leg cast. Monitoring neurovascular status, including circulation and nerve function, is more critical to ensure there are no complications such as compartment syndrome or impaired blood flow.

Choice B rationale

Monitoring capillary refill of the toes is crucial for assessing the circulatory status of the affected limb. Capillary refill time indicates how well blood is perfusing to the extremities. A delayed capillary refill time can suggest compromised circulation, which could lead to serious complications like tissue ischemia. This assessment helps ensure that the cast is not too tight and that there is adequate blood flow to the toes.

Choice C rationale

Examining for spontaneous movement is important for assessing motor function and ensuring that there is no nerve damage. However, it is not as immediate a concern as circulatory assessment. Spontaneous movement can indicate intact motor function, but circulatory compromise would need to be addressed urgently to prevent tissue damage.

Choice D rationale

Palpating femoral pulses is important for assessing the overall circulation to the lower extremities. However, in the context of a long-leg cast, it is more relevant to directly assess the area distal to the cast (such as the toes) for adequate perfusion. Checking femoral pulses alone does not provide specific information about potential compartment syndrome or tightness of the cast affecting distal circulation.

Choice A rationale

Encouraging the child to dress in clothing that suits her sexual maturity level is not an appropriate approach for managing precocious puberty. The goal of treatment with LHRH is to delay further development until the appropriate age, allowing the child to dress according to her chronological age rather than her advanced physical maturity.

Choice B rationale

The purpose of LHRH therapy is to regulate and normalize the child's hormonal levels, which can slow or stop the progression of precocious puberty. As the therapy takes effect, differences in sexual maturity between the child and her peers should diminish over time, allowing her development to align more closely with her age group.

Choice C rationale

LHRH treatment for precocious puberty is typically not lifelong. It is used to delay puberty until a more appropriate age. Once treatment is stopped, the child's body will resume normal pubertal development. Parents should understand that the therapy is temporary and aimed at managing early onset puberty.

Choice D rationale

Starting the child on birth control pills is not a standard treatment for precocious puberty. The goal of LHRH therapy is to manage hormonal levels to delay puberty, not to prevent pregnancy. Birth control pills are not necessary and do not address the underlying condition being treated with LHRH therapy. .