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 A
Explanation
Choice A rationale
Applying a sterile, moist dressing on the sac helps prevent infection and keeps the tissue moist, promoting healing.
Choice B rationale
Monitoring the infant's temperature rectally can increase the risk of infection and is not recommended.
Choice C rationale
Encouraging the guardian to cuddle with the infant is important for bonding but doesn't directly address the care of myelomeningocele.
Choice D rationale
Maintaining the infant in a supine position can put pressure on the sac, increasing the risk of rupture and infection.
Correct Answer is B
Explanation
Choice A rationale
The lap belt fitting snugly over the child's abdomen increases the risk of abdominal injury during a crash.
Choice B rationale
The lap belt fitting low across the child's hips distributes force over stronger bony structures, reducing injury risk.
Choice C rationale
Placing a child in the front seat with a shoulder-only automatic belt does not provide proper restraint and increases injury risk.
Choice D rationale
The shoulder strap crossing just below the child's chin indicates improper fit, posing a risk to the neck in a crash.