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 D
Explanation
Choice A rationale
Introducing well-cooked table foods should begin around 8-10 months of age when the baby is ready for finger foods and has developed better chewing skills.
Choice B rationale
Starting solid foods at 3 months old is too early and can interfere with breastfeeding or formula feeding, increasing the risk of allergies and digestive issues.
Choice C rationale
Cow's milk should not be introduced until 12 months of age, as infants need the nutrients from breast milk or formula during their first year for optimal growth.
Choice D rationale
It is recommended to wait until the baby is at least 6 months old before introducing fruit juice, and even then, it should be given in limited quantities to avoid excessive sugar intake.
Correct Answer is C
Explanation
Choice A rationale
Walks with one hand held typically occurs around 12 months as infants gain balance and coordination for upright movement.
Choice B rationale
Sits unsupported usually happens around 6 months when infants' core muscles are strong enough to hold their torso upright.
Choice C rationale
Turning pages in a book is a fine motor skill that develops around 12 months as hand-eye coordination improves.
Choice D rationale
Rolling from front to back typically occurs around 6 months as infants develop stronger neck and upper body muscles.