A nurse is caring for an adolescent client who has a fractured right tibia and a cast. Which of the following findings should the nurse report to the provider?

Choice A rationale:
Cleaning the infant's suture line with chlorhexidine solution is not indicated immediately after cleft lip repair. The primary concern in the immediate postoperative period is pain management and wound healing, and cleaning the suture line with chlorhexidine could potentially disrupt the healing process.
Choice B rationale:
Applying elbow immobilizers to the infant is not necessary after cleft lip repair. Elbow immobilizers are typically used in situations where there's a need to restrict arm movement, such as preventing a child from bending their arms after certain types of surgery. Cleft lip repair does not involve the arms, so this action is not relevant.
Choice C rationale:
Correct Choice. Offering the infant a pacifier with sucrose for pain relief is appropriate. Non-nutritive sucking, such as using a pacifier, has been shown to have pain-relieving effects in infants. Sucrose, a sweet solution, is often used in combination with non-nutritive sucking to further enhance pain relief during minor procedures or painful experiences. It provides comfort and distraction to the infant, helping to reduce their discomfort.
Choice D rationale:
Placing the infant in a prone position for sleeping is contraindicated after cleft lip repair. Placing an infant prone (on their stomach) for sleep increases the risk of sudden infant death syndrome (SIDS). The recommended sleep position for infants is supine (on their back) to ensure their safety.

Choice A rationale:
Edema. Edema, the accumulation of fluid in the tissues, is not the primary indicator of compartment syndrome. While edema can occur due to various reasons, it's not specific to compartment syndrome. Compartment syndrome primarily involves increased pressure within a closed space (muscle compartment), which can compromise blood circulation and nerve function.
Choice B rationale:
Mottling. Mottling refers to a patchy, bluish discoloration of the skin that occurs due to poor blood circulation and is often seen in critically ill patients. While it might indicate circulatory issues, it's not a direct sign of compartment syndrome. Compartment syndrome is more closely associated with symptoms such as severe pain, numbness, and decreased or absent pulses.
Choice C rationale:
Urticaria. Urticaria, also known as hives, is a skin rash characterized by raised, itchy, and red or white welts. It is typically caused by an allergic reaction or other factors such as medications. Urticaria is unrelated to compartment syndrome, which involves the compression of nerves and blood vessels within a closed anatomical compartment, leading to ischemia and potential tissue damage.
Choice D rationale:
Pulselessness. Pulselessness is a critical sign that the nurse should monitor when conducting a circulatory check for compartment syndrome. Compartment syndrome occurs when there is increased pressure within a confined space (muscle compartment), leading to compromised blood flow and oxygen delivery to the tissues. The lack of a palpable pulse in the affected area suggests that blood flow is severely compromised. This is a late sign of compartment syndrome and requires immediate intervention to prevent tissue necrosis and long-term complications.