A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia.
Which of the following actions should the nurse take?
Discourage the client from ambulating.
Keep the client's leg in a dependent position.
Use a hair dryer on a hot setting to dry the cast.
Perform a neurovascular check of the lower extremities.
The Correct Answer is D
Choice A rationale
Discouraging the client from ambulating is not necessary. In fact, early ambulation is often encouraged to promote circulation and prevent complications, depending on the fracture
type and treatment plan.
Choice B rationale
Keeping the client's leg in a dependent position is not recommended as it can increase swelling and pain. Elevating the leg is typically advised to reduce swelling.
Choice C rationale
Using a hair dryer on a hot setting to dry the cast is unsafe as it can cause burns and damage the cast. It's better to allow the cast to dry naturally and follow the healthcare provider's
instructions.
Choice D rationale
Performing a neurovascular check of the lower extremities is crucial to assess circulation, sensation, and movement. This helps in identifying any complications such as impaired
blood flow or nerve damage.
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Correct Answer is A
Explanation
Choice A rationale
The hepatitis B vaccine is recommended for all newborns within 24 hours of birth to provide early protection against the hepatitis B virus.
Choice B rationale
The PCV (Pneumococcal Conjugate Vaccine) is administered as a series of four doses, typically at 2, 4, 6, and 12-15 months of age.
Choice C rationale
The first dose of the DTaP (Diphtheria, Tetanus, and Pertussis) vaccine is typically given at 2 months of age, not during the initial well-baby visit after birth.
Choice D rationale
The MMR (Measles, Mumps, and Rubella) vaccine is recommended at 12-15 months of age and again at 4-6 years, not at 6 months.
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.