A nurse is caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand.
Which of the following findings should the nurse report immediately to the charge nurse?
The child is not attempting to move her right arm or fingers.
The fingertips of the right hand are swollen and bruised.
The fingers on the right hand have a capillary refill of 4 seconds.
The parent reports the child will not keep the arm elevated on the pillow.
The Correct Answer is C
A nurse caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand should report immediately to the charge nurse if the fingers on the right hand have a capillary refill of 4 seconds.
This could indicate that there is a problem with circulation.
Choice A is not an answer because it is not unusual for a child to not attempt to move her right arm or fingers after having a cast applied.
Choice B is not an answer because it is not unusual for the fingertips of the right hand to be swollen and bruised after having a cast applied.
Choice D is not an answer because it is not unusual for a child to not keep their arm elevated on a pillow after having a cast applied.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should teach the patient to report promptly any edema of the face and hands.
Edema of the face and hands can be a sign of preeclampsia, a serious pregnancy complication that can lead to high blood pressure and damage to organs such as the liver and kidneys.
Preeclampsia can be dangerous for both the mother and the baby and requires prompt medical attention.
Choice A is not an answer because nasal congestion is a common symptom during pregnancy and is not considered a danger sign.
Choice C is not an answer because hemorrhoids are also a common symptom during pregnancy and are not considered a danger sign.
Choice D is not an answer because varicose veins are also a common symptom during pregnancy and are not considered a danger sign.
Correct Answer is C
Explanation
This is an antibiotic ointment that is applied to the eyes of newborns to prevent ophthalmia neonatorum, a serious eye infection caused by gonorrhea.
Ophthalmia neonatorum can cause blindness if left untreated and can occur even if the mother does not have symptoms of gonorrhea.
Erythromycin is the only drug approved by the FDA for this purpose and is mandated in most states.
Choice A.
Nystatin is incorrect, as this is an antifungal medication that is used to treat oral thrush or diaper rash in newborns, not eye infections.
Choice B.
Ceftriaxone is incorrect, as this is an antibiotic injection that is used to treat systemic gonorrhea infections in adults or newborns, not eye infections.
Choice D.
Ofloxacin is incorrect, as this is an antibiotic eye drop that is used to treat bacterial conjunctivitis in older children and adults, not ophthalmia neonatorum in newborns.
Therefore, choice C is the best answer to this question.
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