When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

Change position every 2 hours.

Monitor peripheral pulses and sensation in the right leg.

Cleanse pin sites as prescribed.

Assess skin for redness and signs of tissue breakdown.

Answer and Explanation

The Correct Answer is B

When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the aﬀected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.

Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.

Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.

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Correct Answer is A

Explanation

The nurse should report a positive rapid strep test of the oropharynx to the healthcare provider. Acute glomerulonephritis is often caused by a recent streptococcal infection, and a positive rapid strep test would confirm this as the underlying cause

A blood pressure of 88/50 mmHg is within the normal range for a child and would not need to be reported.

A maculopapular rash over the trunk of the body is not typically associated with acute glomerulonephritis and would not need to be reported.

Weight loss may occur with acute glomerulonephritis due to decreased appetite, but it is not an urgent finding that needs to be reported immediately.

A. The TSH is high because of the low production of T4 by the thyroid. B. The thyroxine level is low because the TSH level is high. C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth. D. High thyroxine levels normally occur in breastfeeding infants.

Correct Answer is A

Explanation

In a normal infant, T4 levels increase after birth due to stimulation by TSH from the pituitary gland. In this case, the T4 level is low and the TSH level is high, indicating that the thyroid gland is not producing enough T4 in response to TSH stimulation. This suggests that the infant may have congenital hypothyroidism, which requires prompt treatment to prevent developmental delays and other complications.

The low T4 level is not a direct cause of the high TSH level; rather, the high TSH level is a compensatory mechanism to increase T4 production. It is not normal for a breastfeeding infant to have high thyroxine levels. While the thyroid gland may take a few weeks to reach normal function after birth, the persistent low T4 and high TSH levels in this infant suggest a more serious issue.

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When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a child with acute glomerulonephritis who presents with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

Correct Answer is A

Explanation

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?

Correct Answer is A

Explanation

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