Maternal and Child Ch.48 The Child with Musculoskeletal or Articular Dysfunction

The nurse is caring for an infant with developmental dysplasia of the hips (DDH). Which clinical manifestations should the nurse expect to observe? (Select all that apply.) A)Unequal gluteal folds B)Positive Ortolani sign C) Negative Babinski's sign D)Trendelenburg's sign E)Telescoping of the affected limb F)Lordosis

A)Unequal gluteal folds B)Positive Ortolani sign A positive Ortolani sign and unequal gluteal folds are clinical manifestations of developmental dysplasia of the hips (DDH) seen from birth to 2 to 3 months. Trendelenburg's sign is noted in a child capable of standing alone. Negative Babinski's sign, telescoping of the affected limb, and lordosis are not clinical manifestations of developmental dysplasia of the hips (DDH).

What effect does immobilization have on the cardiovascular system? A)Venous stasis B)Increased vasopressor mechanism C) Normal distribution of blood volume D)Increased efficiency of orthostatic neurovascular reflexes

A)Venous stasis Because of decreased muscle contraction, the physiologic effects of immobilization include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found, with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes, with an inability to adapt readily to the upright position and pooling of blood in the extremities in the upright position.

Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy? A)Instructions for a low-calorie diet B)Arrangements for tutoring and schoolwork C) Instructions for a high-fat, low-protein diet D)Instructions for the parent to return the child to team sports immediately

B)Arrangements for tutoring and schoolwork Promoting optimal growth and development in the school-age child is important. It is important to continue schoolwork and arrange for tutoring if indicated. The child with osteomyelitis should be on a high-calorie, high-protein diet. The child with osteomyelitis may need time for the bone to heal before returning to full activities.

Which type of traction uses skin traction on the lower leg and a padded sling under the knee? A)Dunlop B)Bryant's C) Russell D)Buck's extension

C) Russell Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position. Dunlop traction is an upper-extremity traction used for fractures of the humerus. Bryant's traction is skin traction with the legs flexed at a 90-degree angle at the hip. Buck's extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, before surgery with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.) A)Palpable distal pulse B)Capillary refill to extremity of <3 seconds C) Severe pain not relieved by analgesics D)Tingling of extremity E) Inability to move extremity

C) Severe pain not relieved by analgesics D)Tingling of extremity E) Inability to move extremity Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity of <3 seconds are expected findings.

A young child has just injured an ankle at school. In addition to calling the child's parents, what is the most appropriate immediate action by the school nurse? A)Apply ice B)Observe for edema and discoloration C) Encourage child to assume a comfortable position D)Obtain parental permission for administration of acetaminophen or aspirin

A)Apply ice Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied. Observing for edema and discoloration, encouraging the child to assume a comfortable position, and obtaining parental permission or administration of acetaminophen or aspirin are not immediate priorities.

Which nursing intervention is appropriate to assess for neurovascular competency in a child suspected of experiencing compartment syndrome? A)The degree of motion and ability to position the extremity. B)The length, diameter, and shape of the extremity. C) The amount of swelling noted in the extremity and pain intensity. D)The skin color, temperature, movement, sensation, and capillary refill of the extremity.

D)The skin color, temperature, movement, sensation, and capillary refill of the extremity. A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree of sensation experienced, and speed of capillary refill in the extremity. The degree of motion in the affected extremity and ability to position the extremity are incomplete assessments of neurovascular competency. The length, diameter, and shape of the extremity are not assessment criteria in a neurovascular evaluation. Although the amount of swelling is an important factor in assessing an extremity, it is not a criterion for a neurovascular assessment.

An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. The nurse's approach should include what intervention? A)Answering questions with straightforward honesty. B)Avoiding discussing the seriousness of the condition. C) Explaining that, although the amputation is difficult, it will cure the cancer. D)Assisting the adolescent in accepting the amputation as better than a long course of chemotherapy.

A)Answering questions with straightforward honesty. Honesty is essential to gain the cooperation and trust of the child. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared in advance for the surgery so that there is time for reflection about the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery.

When assessing the child with osteogenesis imperfecta, the nurse should expect to observe clinical feature? A)Discolored teeth B)Below-normal intelligence C) Increased muscle tone D)Above-average stature

A)Discolored teeth Children with osteogenesis imperfecta have incomplete development of bones, teeth, ligaments, and sclerae. Teeth are discolored because of abnormal enamel. Despite their appearance, children with osteogenesis imperfecta have normal or above-normal intelligence. The child with osteogenesis imperfecta has weak muscles and decreased muscle tone. Because of compression fractures of the spine, the child appears short.

A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse should plan to implement which interventions for this child? (Select all that apply.) A)Instructions to avoid exposure to sunlight B)Teaching about body changes associated with SLE C) Preparation for home schooling D)Restricted activity

A)Instructions to avoid exposure to sunlight B)Teaching about body changes associated with SLE Key issues for a child with SLE include therapy compliance; body-image problems associated with rash, hair loss, and steroid therapy; school attendance; vocational activities; social relationships; sexual activity; and pregnancy. Specific instructions for avoiding exposure to the sun and ultraviolet B light, such as using sunscreens, wearing sun-resistant clothing, and altering outdoor activities, must be provided with great sensitivity to ensure compliance while minimizing the associated feeling of being different from peers. The child should continue school attendance in order to gain interaction with peers and activity should not be restricted, but promoted.

Four year old, placed in Buck's extension traction for Legg-Calvé-Perthes disease, is crying with pain as the nurse assesses that the skin of the right foot is pale with an absence of pulse. What should the nurse do first? A)Notify the practitioner of the changes noted. B)Give the child medication to relieve the pain. C) Reposition the child and notify the physician. D)Chart the observations and check the extremity again in 15 minutes.

A)Notify the practitioner of the changes noted. The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. Pain medication and repositioning should be addressed after the practitioner is notified. This is an emergency condition; immediate reporting is indicated. The findings should be documented with ongoing assessment.

Which condition can result from the bone demineralization associated with immobility? A)Osteoporosis B)Urinary retention C) Pooling of blood D)Susceptibility to infection

A)Osteoporosis Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.

Discharge planning for the child diagnosed with juvenile arthritis includes the need for which intervention? A)Routine ophthalmologic examinations to assess for visual problems. B)A low-calorie diet to decrease or control weight in the less mobile child. C) Avoiding the use of aspirin to decrease gastric irritation. D)Immobilizing the painful joints, which are the results of the inflammatory process.

A)Routine ophthalmologic examinations to assess for visual problems. The systemic effects of juvenile arthritis can result in visual problems, making routine eye examinations important. Children with juvenile arthritis do not have problems with increased weight and often are anorexic and in need of high-calorie diets. Children with arthritis are often treated with aspirin. Children with arthritis are able to immobilize their own joints. Range-of-motion exercises are important for maintaining joint flexibility and preventing restricted movement in the affected joints.

Which term is used to describe a type of fracture that does not produce a break in the skin? A)Simple B)Compound C) Complicated D)Comminuted

A)Simple If a fracture does not produce a break in the skin, it is called a simple or closed fracture. A compound or open fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue. These are rare in children.

A child is upset because, when the leg cast is removed, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material? A)Soak in a bathtub B)Vigorously scrub the leg C) Apply powder to absorb material D)Carefully pick material off of the leg

A)Soak in a bathtub Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child.

What is an advantage to using a fiberglass cast instead of a plaster cast? A)Is less expensive B)Dries rapidly C) Molds closely to body parts D)Has a smooth exterior

B)Dries rapidly A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive. Plaster casts mold closer to body parts. Synthetic casts have a rough exterior, which may scratch surfaces.

The nurse uses the palms of the hands when handling a wet cast to achieve what outcome? A)Assess dryness of the cast B)Facilitate easy turning C) Keep the patient's limb balanced D)Avoid indenting the cast

D)Avoid indenting the cast Wet casts should be handled by the palms of the hands, not the fingers, to prevent creating pressure points. Assessing dryness, facilitating easy turning, or keeping the patient's limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast.

What is an appropriate nursing intervention when caring for a child in traction? A)Remove adhesive traction straps daily to prevent skin breakdown. B)Assess for tightness, weakness, or contractures in uninvolved joints and muscles. C) Provide active range-of-motion exercises to affected extremity 3 times a day. D)Keep child in one position to maintain good alignment.

B)Assess for tightness, weakness, or contractures in uninvolved joints and muscles. Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released/replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained.

The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complication should the nurse monitor for? A)Hypocalcemia B)Decreased metabolic rate C) Positive nitrogen balance D)Increased production of stress hormones

B)Decreased metabolic rate Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake, leads to hypercalcemia, and causes a negative nitrogen balance secondary to muscle atrophy. A decreased production of stress hormones occurs with decreased physical and emotional coping capacity.

A 10 year old sustained a fracture in the epiphyseal plate of the right fibula when falling from a tree. When discussing this injury with the child's parents, the nurse should consider which statement? A)Healing is usually delayed in this type of fracture. B)Growth can be affected by this type of fracture. C) This is an unusual fracture site in young children. D)This type of fracture is inconsistent with a fall.

B)Growth can be affected by this type of fracture. Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected. Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point of the long bones. This is a frequent site of damage during trauma.

A nurse is conducting discharge teaching for parents of an infant diagnosed with osteogenesis imperfecta (OI). Further teaching is indicated if the parents make which statement? A)"We will be very careful handling the baby." B)"We will lift the baby by the buttocks when diapering." C) "We're glad there is a cure for this disorder." D)"We will schedule follow-up appointments as instructed."

C) "We're glad there is a cure for this disorder." The treatment for OI is primarily supportive. Although patients and families are optimistic about new research advances, there is no cure. The use of bisphosphonate therapy with IV pamidronate to promote increased bone density and prevent fractures has become standard therapy for many children with OI; however, long bones are weakened by prolonged treatment. Infants and children with this disorder require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved, and held. Even changing a diaper may cause a fracture in severely affected infants. These children should never be held by the ankles when being diapered but should be gently lifted by the buttocks or supported with pillows. Follow-up appointments for treatment with bisphosphonate can be expected.

When infants are seen for fractures, which nursing intervention is a priority? A)No intervention is necessary. It is not uncommon for infants to fracture bones. B)Assess the family's safety practices. Fractures in infants usually result from falls. C) Assess for child abuse. Fractures in infants are often nonaccidental. D)Assess for genetic factors.

C) Assess for child abuse. Fractures in infants are often nonaccidental. Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are unusual because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones. Infants should be cared for in a safe environment and should not be falling. Fractures in infancy are usually nonaccidental rather than related to a genetic factor.

When does idiopathic scoliosis become most noticeable? A)Newborn period B)When child starts to walk C) During preadolescent growth spurt D)Adolescence

C) During preadolescent growth spurt Idiopathic scoliosis is most noticeable during the preadolescent growth spurt and is seldom apparent before age 10 years.

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should base the explanation on what fact? A)Traction is tried first. B)Surgical intervention is needed. C) Frequent, serial casting is tried first. D)Children outgrow this condition when they learn to walk.

C) Frequent, serial casting is tried first. Serial casting, the preferred treatment, is begun shortly after birth before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hips (DDH). What information should be included? A)Apply lotion or powder to minimize skin irritation. B)Remove the harness several times a day to prevent contractures. C) Hip stabilization usually occurs within 12 weeks. D)Place a diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

C) Hip stabilization usually occurs within 12 weeks. The harness is worn continuously until the hip is proved stable on both clinical and ultrasound examination, usually within 6 to 12 weeks. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

What is the initial method of treating osteomyelitis? A)Joint replacement B)Bracing and casting C) Intravenous antibiotic therapy D)Long-term corticosteroid therapy

C) Intravenous antibiotic therapy Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics delivered intravenous and then possibly by the oral route. Joint replacement, bracing and casting, and long-term corticosteroids are not indicated for infectious processes.

What nursing consideration is especially important when caring for a child diagnosed with juvenile idiopathic arthritis (JIA)? A)Apply ice packs to relieve stiffness and pain. B)Administer acetaminophen to reduce inflammation. C) Teach child and family the correct administration of medications. D)Encourage range-of-motion exercises during periods of inflammation.

C) Teach child and family the correct administration of medications. The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of a regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that nonsteroidal antiinflammatory drugs should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects. Range-of-motion exercises should not be done during periods of inflammation.

What would cause a nurse to suspect that an infection has developed under a cast? A)Complaint of paresthesia B)Cold toes C) Increased respirations D)"Hot spots" felt on cast surface

D)"Hot spots" felt on cast surface If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so a window can be made in the cast to observe the site. The "five Ps" of ischemia from a vascular injury include pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may indicate a respiratory infection or pulmonary emboli. This should be reported, and the child should be evaluated.

The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching? A)Swelling of the fingers is to be expected for the next 48 hours. B)Immobilize the shoulder to decrease pain in the arm. C) Allow the affected limb to hang down for 1 hour each day. D)Elevate casted arm when resting and when sitting up.

D)Elevate casted arm when resting and when sitting up. The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged.

Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? A)Scoliosis B)Ankylosis C) Lordosis D)Kyphosis

D)Kyphosis Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint. Lordosis is an accentuation of the cervical or lumbar curvature beyond physiologic limits.

Which medication is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? A)Aspirin B)Corticosteroids C) Cytotoxic drugs such as methotrexate D)Nonsteroidal antiinflammatory drugs (NSAIDs)

D)Nonsteroidal antiinflammatory drugs (NSAIDs) NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children. Aspirin, once the drug of choice, has been replaced by the NSAIDs because they have fewer side effects and easier administration schedules. Corticosteroids are used for life-threatening complications, incapacitating arthritis, and uveitis. Methotrexate is a second-line therapy for JIA.

A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations should include which action? A)Encouraging normal activity for as long as is possible. B)Explaining the cause of the disease to the child and family. C) Preparing the child and family for long-term, permanent disabilities. D)Teaching the family the care and management of the corrective appliance.

D)Teaching the family the care and management of the corrective appliance. The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome. The initial therapy is rest and nonweight bearing, which helps reduce inflammation and restore motion. Legg-Calvé-Perthes is a disease with an unknown etiology. A disturbance of circulation to the femoral capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is self-limiting, but the ultimate outcome of therapy depends on early and efficient therapy and the child's age at onset.