A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
The parent reports the child will not keep the arm elevated on the pillow.
The fingers on the right hand have a capillary refill of 4 seconds.
The fingertips of the right hand are swollen and bruised.
The child is not attempting to move her right arm or fingers.
The Correct Answer is B
A. The parent reports the child will not keep the arm elevated on the pillow: Not a priority. While elevation is important, it is not immediately concerning.
B. The fingers on the right hand have a capillary refill of 4 seconds: Correct. A capillary refill time of more than 2 seconds indicates poor perfusion, which can be a sign of compartment syndrome, a serious complication.
C. The fingertips of the right hand are swollen and bruised: Concerning, but swelling and bruising can be normal post-injury. Immediate concern is perfusion.
D. The child is not attempting to move her right arm or fingers: Concerning, but can be due to pain or fear. Poor perfusion (B) is a more immediate threat.
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Related Questions
Correct Answer is C
Explanation
A. Attempt to obtain a throat culture: This is contraindicated because manipulating the throat could exacerbate airway obstruction, leading to a potential respiratory emergency.
B. Use a tongue depressor to observe the back of the throat: This can provoke a spasm or cause complete airway obstruction in a child with epiglottitis and should be avoided.
C. Apply humidified oxygen via a mask: This helps to keep the airways moist and can provide some relief and improve oxygenation while minimizing the risk of airway manipulation.
D. Initiate airborne precautions: Epiglottitis primarily requires droplet precautions, not airborne. Airborne precautions are used for diseases like tuberculosis, which are spread through smaller droplets that remain suspended in the air.
Correct Answer is A
Explanation
A. Rotavirus: The rotavirus vaccine is recommended for infants at 2, 4, and possibly 6 months of age, depending on the vaccine formulation. It helps protect against rotavirus, which can cause severe diarrhea and dehydration in infants.
B. Measles, mumps, rubella (MMR): The MMR vaccine is not given until 12-15 months of age. It is not part of the vaccination schedule for a 4-month-old infant.
C. Varicella (VAR): The varicella vaccine is typically administered at 12-15 months of age. It is not appropriate for a 4-month-old infant.
D. Influenza: The influenza vaccine is recommended annually starting at 6 months of age. A 4-month-old is too young to receive the influenza vaccine.
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