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 A
Explanation
Choice A rationale
Asymmetric thigh folds are a common sign of developmental dysplasia of the hip (DDH) in infants. This physical examination finding indicates that the hips are not aligned properly, which can cause the folds in the thighs to appear uneven.
Choice B rationale
A shortened thigh, rather than a lengthened one, on the affected side is more typical of DDH. It is due to the femoral head not being properly seated in the hip socket, which can cause a discrepancy in leg length.
Choice C rationale
An inwardly turned foot is not a characteristic finding of DDH. This symptom is more commonly associated with conditions affecting the feet and lower legs, such as clubfoot.
Choice D rationale
The absence of plantar reflexes is not typically associated with DDH. This reflex involves a different part of the nervous system and is not linked to hip dysplasia.