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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Breastfeeding frequently is generally recommended for infant health, but it is not specifically related to preventing otitis media recurrence. It has other health benefits for infants.
B. Positioning the infant prone (face down) after feeding is not recommended, and it does not relate to preventing otitis media recurrence. The recommended sleep position for infants is on their back to reduce the risk of sudden infant death syndrome (SIDS).
C. Avoiding smoke exposure is a crucial instruction for preventing otitis media recurrence. Exposure to secondhand smoke is a known risk factor for ear infections in children. It can lead to increased susceptibility to respiratory infections, which can subsequently increase the risk of otitis media.
D. Inspecting the infant's ears daily is not a primary preventive measure for otitis media recurrence. While it's essential to monitor the child's health, checking the ears daily is not a standard practice for preventing ear infections.
Correct Answer is D
Explanation
A. Normal gait can be expected with appropriate management and treatment for clubfoot. With early and effective intervention, many children with clubfoot can achieve a normal gait.
B. Growth and development are not typically delayed as a long-term outcome of clubfoot when it is appropriately managed. The goal of treatment is to achieve normal foot development and function.
C. While heredity can play a role in clubfoot, it is not typically a sole determinant of the outcome. The success of treatment primarily depends on the timeliness and effectiveness of the interventions.
D Correction will require serial casting.
Unilateral clubfoot is a congenital deformity of the foot that can often be effectively managed with non-surgical interventions. Serial casting is a common and successful approach used to gradually correct the deformity. Parents should be informed that serial casting is likely to be a part of the treatment plan for their child's clubfoot.
Therefore, it is essential to educate parents that correction of unilateral clubfoot will likely require serial casting and that with appropriate treatment, the child can achieve a normal gait and experience normal growth and development.
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