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 C
Explanation
Choice A rationale
A properly fastened harness and securely anchored car seat are essential for infant safety. This statement indicates correct practice and does not require further teaching.
Choice B rationale
Using an infant model car seat that is securely anchored is appropriate for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.
Choice C rationale
A front-facing car seat is inappropriate for a 6-month-old infant. Infants should ride in a rear-facing car seat until at least the age of 2 or until they reach the highest weight or height allowed by the car seat manufacturer. This statement indicates a need for further teaching.
Choice D rationale
A rear-facing car seat in the back passenger seat is the safest position for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.
Correct Answer is C
Explanation
Choice A rationale
The infant's birth weight typically doubles by 4-6 months and triples by 1 year of age. If an infant's weight has tripled at 6 months, it may indicate overnutrition or an underlying health condition.
Choice B rationale
Lateral incisors usually appear between 9 to 13 months. At 6 months, the central incisors are more likely to be emerging.
Choice C rationale
The posterior fontanel typically closes by 2 to 3 months of age. Therefore, by 6 months, it is expected to be closed.
Choice D rationale
Infants usually sit without support around 8 months. At 6 months, they may sit with support or briefly without support but not consistently.