During a well baby clinic visit, the mother of a 6-month-old infant asks the nurse if she can have a prescription for liquid multivitamin with fluoride. Though the infant is still breast feeding, the mother provides the child with supplemental formula feedings. Which assessment is most important for the nurse to obtain?

A. Cleansing pin sites as prescribed is important for infection prevention, but it is not the most critical intervention in the context of assessing vascular and neurologic status.

B. Monitor peripheral pulses and sensation in the right leg.

Balanced suspension skeletal traction is used to stabilize fractures or treat certain orthopedic conditions. Monitoring peripheral pulses and sensation in the right leg is a critical aspect of caring for a child in this type of traction. It is essential to ensure that the child's circulation and nerve function are not compromised. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.

C. Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensation when the child is in traction.

D. Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.

Peripheral pulses and sensation must be closely monitored and documented at regular intervals to ensure the child's safety and the effectiveness of the traction. Any changes in these parameters should be promptly reported to the healthcare provider.

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.