A nurse is providing care to a child who was placed in 90-90 skeletal traction 12 hr ago. Which of the following actions should the nurse take?
Encourage the child to use the trapeze bar for position changes.
Maintain the child's leg in an extended position while in traction.
Perform neurovascular assessment on the affected extremity every 4 hr.
Release the child's traction weights when changing bed linens.
The Correct Answer is A
Choice A reason: Encouraging the child to use the trapeze bar for position changes promotes mobility, independence, and prevents complications such as skin breakdown. It allows safe repositioning without disrupting traction alignment. This is the correct intervention.
Choice B reason: Maintaining the leg in an extended position is incorrect because 90-90 traction requires the hip and knee to be flexed at 90 degrees. Extending the leg would disrupt the traction setup and compromise healing.
Choice C reason: Neurovascular assessments should be performed more frequently than every 4 hours, especially in the first 24 hours after traction initiation. The standard is every 1–2 hours initially to detect early signs of impaired circulation. Therefore, every 4 hours is insufficient.
Choice D reason: Traction weights should never be released unless specifically ordered by the provider. Removing weights disrupts the traction system, compromises bone alignment, and increases the risk of complications. This makes the option unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Varicella zoster (chickenpox) is transmitted via airborne droplets and direct contact with lesions. The nurse must wear a mask to prevent inhalation of airborne particles. Airborne precautions are essential to protect healthcare workers and other patients from infection.
Choice B reason: Wiping the stethoscope with alcohol-based gel is a standard infection control practice, but it is not specific to varicella zoster precautions. While important, it does not address the airborne transmission risk.
Choice C reason: Positive-pressure airflow rooms are used for clients who need protection from outside contaminants, such as those who are immunocompromised. For airborne infections like varicella, negative-pressure rooms are indicated to prevent contaminated air from escaping into the hallway. Positive-pressure airflow would increase the risk of spreading the infection.
Choice D reason: Allowing private playroom time does not prevent transmission. The toddler should remain in isolation until lesions have crusted over to prevent spreading the virus. This option does not address infection control needs.
Correct Answer is A
Explanation
Choice A reason: Prolonged uterine contractions lasting 90 seconds indicate uterine tachysystole, a dangerous adverse effect of oxytocin. This can reduce placental perfusion, compromise fetal oxygenation, and increase risk of uterine rupture. Immediate intervention is required.
Choice B reason: Moderate variability of the fetal heart rate is a reassuring sign of adequate oxygenation and intact neurological function. It is not an adverse effect.
Choice C reason: Contractions every 2 minutes are within the normal therapeutic range for oxytocin augmentation. This frequency supports labor progression without compromising fetal well-being.
Choice D reason: A fetal heart rate of 150/min is within the normal baseline range (110–160/min). This is not an adverse effect.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.