When providing care for a child who is 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?

Cleanse pin sites as prescribed.

Monitor peripheral pulses and sensation in the right leg.

Assess skin for redness and signs of tissue breakdown.

Change position every 2 hours.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

A. Regular syringe feedings alone do not necessarily promote rapid weight gain, and their appropriateness depends on the underlying cause of FTT and the healthcare provider's recommendations.

B. Breast milk provides adequate calories for the child.

Breast milk is an excellent source of nutrition for infants, providing essential nutrients and calories needed for healthy growth and development. It is generally well-tolerated and suitable for most infants. Encouraging breastfeeding, especially if the infant is not exclusively breastfed, can be a valuable approach in managing FTT.

C. Fruit juice, particularly in excess, may not be recommended for infants with FTT as it can be high in sugars and low in essential nutrients. It is not a primary intervention for FTT.

D. High-calorie formula can be considered for infants with FTT, but it should be prescribed and monitored by a healthcare provider. Simply using high-calorie formula without proper guidance is not an appropriate intervention.

Breast milk is a valuable and appropriate source of nutrition for infants with FTT, and the nurse should support and encourage its use while monitoring the infant's growth and progress closely.

A. Olive-size mass in the epigastric area. B. Stool that consists of mucus and blood. C. Rebound tenderness in the left lower abdominal quadrant. D. Frequent burping accompanied by poor feeding

Correct Answer is A

Explanation

Projectile vomiting in a 5-week-old infant can be indicative of a condition known as pyloric stenosis. Pyloric stenosis is a narrowing of the pylorus, the opening from the stomach to the small intestine. It results in delayed gastric emptying, leading to the forceful, projectile vomiting observed after feedings.

A. An olive-size mass in the epigastric area is a characteristic finding in infants with pyloric stenosis. The hypertrophied pyloric muscle feels like an olive and is often palpable in the upper abdomen.

B. Stool that consists of mucus and blood is not a typical finding associated with pyloric stenosis. This symptom is more suggestive of gastrointestinal issues like infectious colitis or other conditions unrelated to pyloric stenosis.

C. Rebound tenderness in the left lower abdominal quadrant is not a common finding in infants with pyloric stenosis. Rebound tenderness is typically associated with conditions like appendicitis in a different part of the abdomen.

D. Frequent burping accompanied by poor feeding can be a sign of discomfort but is not a specific indicator of pyloric stenosis. Projectile vomiting is a more distinctive symptom associated with this condition.

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When providing care for a child who is 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?

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Correct Answer is B

Explanation

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Correct Answer is A

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