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The nurse is continuing to care for the child.

Exhibits

Complete the following sentence by using the lists of options.

The child is at highest risk for developing

as evidenced by the child's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Rationale for Correct Choices:

  • Compartment Syndrome: Compartment syndrome is a limb-threatening condition that occurs when increased pressure within a muscle compartment impairs circulation and nerve function. The child has a nondisplaced fracture of both the radius and ulna, along with edema, ecchymosis, and fingers that are cool to touch, all of which are early signs of compromised perfusion.
  • Tingling Sensation: Tingling (paresthesia) is an early neurological sign of impaired sensory function often seen in the early stages of compartment syndrome. This child verbalizes a mild tingling in the fingers, which indicates nerve compression due to increased pressure within the forearm compartments.

Rationale for Incorrect Choices

  • Paresthesia: Tingling is the hallmark symptom of paresthesia, but paresthesia is a symptom, not a disease process. The nurse must determine the underlying cause of the altered sensation, which in this situation is likely compartment syndrome.
  • Deep Vein Thrombosis (DVT): DVT typically presents with unilateral leg swelling, warmth, pain, and sometimes redness—not forearm injury symptoms. The child has a forearm fracture and bruises on the lower extremities in different healing stages, but there's no localized swelling, erythema, or immobility in the legs to support a DVT diagnosis.
  • Pain Level: A pain score of 4 out of 10 is not severe enough to support compartment syndrome or any acute vascular crisis alone. Pain that is out of proportion to the injury and unrelieved by medication would raise concern.
  • Mobility: The child is ambulatory and able to move their fingers and limbs, which reduces the likelihood of venous stasis a major risk factor for DVT. In the absence of prolonged immobility or systemic hypercoagulability, there is minimal reason to suspect a thrombotic event based on mobility alone.


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for correct choices:

  • Macrosomia: Post-term infants (≥42 weeks gestation) have prolonged exposure to intrauterine nutrients, increasing the risk of excessive fetal growth. Macrosomia is common and can lead to complications such as shoulder dystocia or birth trauma.
  • Meconium aspiration syndrome: As gestation progresses beyond term, placental function may decline, increasing fetal stress. This can trigger passage of meconium in utero and aspiration during delivery, especially with late decelerations suggesting uteroplacental insufficiency.

Rationale for incorrect choices:

  • Intraventricular hemorrhage: This condition is typically associated with preterm infants due to fragile cerebral vasculature. A post-term newborn is not at increased risk for IVH.
  • Bronchopulmonary dysplasia: BPD is a chronic lung disease most often seen in premature infants requiring prolonged mechanical ventilation and oxygen therapy. It is not a common concern for post-term infants.

Correct Answer is C

Explanation

Rationale:

A. "Begin each feeding using the same breast.": It's recommended to alternate breasts between feedings to ensure both breasts are emptied regularly. This helps maintain milk production and prevents engorgement or blocked ducts.

B. "Supplement breastfeedings with water every 12 hours.": Newborns do not require supplemental water. Breast milk provides all the necessary hydration and nutrients for the infant’s needs, even in hot weather.

C. "Offer your infant the breast when he shows signs of hunger.": Feeding on demand based on hunger cues—such as rooting, sucking motions, or hand-to-mouth activity—supports adequate nutrition, growth, and milk supply.

D. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding should not be time-restricted. Infants should be allowed to feed until they are satisfied, as some may take longer to extract enough milk, especially in the early weeks.

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