A nurse is caring for a school-age child who has a fracture to the right femur.
Which of the following findings is the nurse's priority?
Capillary refill less than 2 seconds.
Tingling in the right foot.
Respiratory rate 24/min.
2+ right pedal pulse.
The Correct Answer is B
Choice A rationale
Capillary refill less than 2 seconds is a normal finding and suggests adequate perfusion. It is not indicative of a priority concern in this context.
Choice B rationale
Tingling in the right foot can indicate nerve damage or compromised circulation, which is critical to address in a patient with a fracture. This symptom could suggest complications like compartment syndrome, requiring immediate medical attention.
Choice C rationale
Respiratory rate of 24/min is slightly elevated but not directly related to the fracture's immediate complications. It requires monitoring but is not the priority.
Choice D rationale
A 2+ right pedal pulse indicates a normal pulse and adequate circulation in the foot. While important, it does not represent an immediate concern in this context.
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Correct Answer is B
Explanation
Choice A rationale
Infants typically do not double their birth weight by 2-3 months. This milestone is more commonly reached slightly later in infancy.
Choice B rationale
By 5-6 months, many infants double their birth weight, indicating healthy growth and development. This timeline aligns with common pediatric growth patterns.
Choice C rationale
While growth continues at a steady pace, most infants have already doubled their birth weight before reaching 9 months. This age generally marks further physical and
developmental milestones.
Choice D rationale
By 12 months, infants have typically more than doubled their birth weight. This age is associated with continued growth, development, and new milestones.
Correct Answer is C
Explanation
Choice A rationale
Administering syrup of ipecac to induce vomiting is no longer recommended due to the risk of aspiration and potential harm from the substance ingested.
Choice B rationale
Giving orange juice won't counteract iron poisoning from ferrous sulfate and may actually increase iron absorption, exacerbating the situation.
Choice C rationale
Contacting the poison control center is the most appropriate action as they provide expert guidance on managing iron overdose and other poisoning scenarios.
Choice D rationale
Providing a high-carbohydrate snack is not relevant or effective in treating iron poisoning and can delay appropriate medical intervention.