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

Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.

Choice B rationale

Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.

Choice C rationale

Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.

Choice D rationale

Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.