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
A. Lateral incisors are present:At 6 months, infants typically begin teething, but the lateral incisors usually do not appear until around 9 to 13 months. The first teeth to emerge are usually the lower central incisors.
B. Posterior fontanel is closed:The posterior fontanel, or the soft spot at the back of the baby's head, typically closes by 2 to 3 months of age. Therefore, it is expected to be closed by the time the infant is 6 months old.
C. Infant's birth weight is tripled:By 6 months, infants generally double their birth weight. Tripling of birth weight is more commonly expected by the end of the first year.
D. Infant sits well without support:Most infants begin to sit without support around 7 to 9 months. At 6 months, they may sit with some support but are not yet expected to sit well independently.
Correct Answer is D
Explanation
Checking the baby’s skin three times each day can help the mother monitor for any skin irritation or breakdown caused by the harness.
This can help prevent complications and ensure that the harness is being used safely and effectively.
Choice A is not the best answer because the mother should not adjust the harness straps on her own.
This should be done by a healthcare provider to ensure that the harness is properly fitted.
Choice B is not the best answer because the diaper should be placed under the harness, not over it.
Choice C is not the best answer because massaging lotion on the skin around the harness clasps may not be necessary and could potentially cause skin irritation.
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