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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Acetaminophen can be used to reduce fever during pregnancy.
Choice A is incorrect because misoprostol is not used to treat fever during labor.
Choice C is incorrect because the placement of an intrauterine pressure catheter is not used to treat fever during labor.
Choice D is incorrect because simply rechecking the client’s temperature in 2 hours does not address the issue of the client’s fever.
Correct Answer is A
Explanation
This is a diagnostic procedure that involves inserting a needle into the uterus to obtain a sample of amniotic fluid for testing.
This procedure can cause a small amount of fetal blood to enter the maternal circulation, which can trigger an immune response in Rh-negative women carrying Rh-positive fetuses.
RhoGAM is a medication that contains antibodies against the Rh factor and prevents the mother from developing her own antibodies that could harm the fetus or future pregnancies.
RhoGAM should be given within 72 hours after amniocentesis to Rh-negative women who are not already sensitized2.
Choice B.
Biophysical Profile is incorrect, as this is a noninvasive diagnostic procedure that involves ultrasound and fetal heart rate monitoring to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice C.
The contraction stress test is incorrect, as this is a noninvasive diagnostic procedure that involves inducing uterine contractions and monitoring fetal heart rate response to assess fetal oxygenation.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice D.
A nonstress test is incorrect, as this is a noninvasive diagnostic procedure that involves monitoring fetal heart rate and movement to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Therefore, choice A is the best answer to this question.
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