Ricci Chapter 44: Nursing Care of the Child With an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder

A parent calls the clinic nurse to say the child has shin splints after playing soccer. What instructions should the nurse provide this parent?

"Applying ice to the area will reduce pain and swelling" Shin splints are a form of an overuse syndrome. These syndromes occur when there is repeated force applied to connective tissue, causing it to break down. The first line of treatment for these injuries is RICE (rest, ice, compression, elevation). Cold should be applied for 20 to 30 minutes and then removed for 60 minutes. This process is repeated until area is numb. Cold causes vasoconstriction to reduce the pain and swelling. As part of RICE, the legs should be elevated, but there is no timeline for how long this should occur. Warm baths would cause vasodilation, further increasing the pain and swelling.

The nurse is speaking with the parents of a child who has a cast. The parents state that the child reports itching in the area of the cast. What is the best response by the nurse?

"Blowing cool air with a fan or hairdryer may relieve the feeling" Itching is a common report, but just stating this does not address the entire situation. The suggestion of blowing cool air is the best answer. Clients should never put anything in a cast to scratch. Lotion may be applied to the skin above or below a cast but should never be poured into a cast.

The nurse is caring for a child requiring a cast. The mother asks why the doctor is recommending a fiberglass cast when it is more expensive. What information should the nurse share with the mother? Select all that apply

"Fiberglass casts are lighter in weight than plaster casts." "They can be waterproof when a special liner is used." "Kids like them because they come in different colors." Fiberglass casts are lighter, come in a variety of colors, and when a special liner is used, can be waterproof. Because of the cost, plaster casts are typically used when frequent cast changes are needed. Plaster casts, not fiberglass, take longer to dry.

The emergency department nurse is caring for a 3-year-old girl with an arm injury. The mother is very upset because she believes she broke her daughter's arm. "I was lifting her by her hands and felt a pop in her wrist. She instantly started screaming." The child is now guarding and refusing to move her arm. Which response by the nurse would be most appropriate?

"Her arm isn't broken. This injury is common and easily fixed with no complications." The nurse should quickly reassure the mother that this is a common occurrence, seen every day in the emergency department, and is easily fixed and resolves with no complications. Although a popping noise indicates entrapment of the ligament, this response does not address the mother's concerns. Although the radial head most likely dislocated, this response does not address the mother's concern. Although this condition is called nursemaid's elbow, telling the mother she has to be more careful only serves to put blame on the mother and does not address her concerns.

The young child is experiencing muscle spasms and has been given lorazepam. Which statements by the child indicate that the child may be experiencing some common side effects? Select all that apply.

"I feel sort of dizzy." "I need to take a nap." This child has taken a benzodiazepine. Common side effects associated with this medication are dizziness and sedation. The skeletal muscle relaxes and the spasms will diminish. Nausea and upper gastrointestinal pain are not common side effects associated with this medication.

The parents of a infant born with an abnormality on the back are told by the neonatologist that their child has a myelomeningocele. They ask the nurse what exactly that means. Which would be the nurse's best reply?

"It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved." A myelomeningocele is the more severe form of spina bifida cystica, in which the spinal cord and nerve roots herniate into the sac through an opening in the spine, compromising the meninges and usually resulting in neurological impairment. A meningocele includes the meninges and spinal fluid only. A myelomeningocele usually contains the bowel and bladder innervation but involves many more nerves also. A myelomeningocele is not just a cyst that resolves within a year.

A nurse is teaching the parents of a child who has been diagnosed with spina bifida. Which statement by the nurse would be the most accurate description of spina bifida?

"Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately." When a spinal cord lesion exists at birth, it commonly leads to altered development or function of other areas of the CNS. Spina bifida is a complex neurologic defect that heavily impacts the physical, cognitive, and psychosocial development of the child and involves collaborative, lifelong management due to the chronicity and multiplicity of the problems involved.

A nurse is assisting the parents of an infant who requires a Pavlik harness. The parents are apprehensive about how to care for their infant and concerned about holding and playing with the infant. How can the nurse best assist the parents?

"Let's put you in touch with other families who have experienced this" A Pavlik harness is used to reduce and stabilize the hip by preventing hip extension and adduction and maintaining the hip in flexion and abduction. It can be very daunting for parents to care for their child in this device. There are many helpful pointers and suggestions that are available from other parents and orthopedic organizations. Referring the parents to other families who have experienced a Pavlik harness will provide assurance and likely increase compliance with the regimen. The other responses are factual but do not address the parent's concerns.

A nurse is providing instructions for home cast care. Which response by the parent indicates a need for further teaching?

"Pale, cool, or blue skin coloration is to be expected" It is very important to teach parents to identify the signs of neurovascular compromise (pale, cool, or blue skin) and tell them to notify the physician immediately. The other statements are correct.

A young child with Duchenne muscular dystrophy is placed on both prednisone and calcium. Parents view these two medications as rather "common" and question their importance for the child. What explanation by the nurse will be most helpful to the parents?

"Prednisone helps to keep muscle fibers strong and delays progression of the disease. Calcium protects against osteoporosis caused by both prednisone and lack of weight bearing." Studies have shown that boys treated with prednisone have improved muscle strength and function. This is thought to be due to the protection that prednisone provides to muscle fibers. Calcium is needed to prevent osteoporosis, which is a side effect of prednisone that also occurs when weight bearing is limited. Respiratory infection is a risk in that those muscles weaken with progression of the disease, but reactive airway disease is not a particular risk. No peripheral nerve involvement is observed in Duchenne muscular dystrophy. Side effects of prednisone include weight gain and appetite stimulation, but these are not the reasons for the prednisone therapy. Calcium does augment dietary intake of the mineral and is important for tooth development, and it may play a role in prevention of muscle cramps, but these are not the main reasons for taking the calcium supplement.

The nurse has been teaching the parents of a child diagnosed with osteogenesis imperfecta about the use of bisphosphonates for this condition. What statement by a parent indicates a need for further education?

"The medication will cure my child of this disorder" Bisphosphonates are used in the palliative, not curative, treatment of osteogenesis imperfecta. The medication increases bone mineral density, therefore reducing the risk of the child developing fractures. The medication does not actually prevent fractures from happening.

The nurse is caring for a child who has a hip spica cast. The child's mother asks why is there a hole cut in it. What is the best response by the nurse?

"The window helps us assess bowel sounds and helps to prevent abdominal distension" A window in placed over the abdomen in a body or hip spica cast to prevent abdominal distention and allow bowel sounds to be assessed. The window in a spica cast does not prevent compartment syndrome from happening.

A nurse is caring for a 13-year-old boy with Duchenne muscular dystrophy. He says he feels isolated and that there is no one who understands the challenges of his disease. How should the nurse respond?

"There are a lot of kids with the same type of muscular dystrophy you have at the MDA support group." The best response would be to remind the boy that there are many children with muscular dystrophy that could be found at the local support group. Teenagers do not like to be told that they "have" to do anything. Telling the boy that he needs to be active or simply suggesting activities does not address his concerns.

After teaching the parents of a 6-year-old child about caring for a sprained wrist, which statement by the parents indicates the need for additional teaching?

"We'll apply a warm moist compress to the wrist for 20 minutes at a time" Care for a sprain includes rest, ice, compression, and elevation. Cold therapy, not heat, is used for 20 to 30 minutes at a time, then removed for 1 hour and repeated for the first 24 to 48 hours. Compression via an elastic bandage, elevating above heart level, and limiting activity are appropriate measures.

A 13-year-old adolescent is being treated for scoliosis with a brace. During the first follow-up appointment after the brace was initiated, which statement by the adolescent indicates the need for further instruction?

"When I get home from school, I look forward to taking off my brace for a few hours before I go to bed" Scoliosis refers to the lateral curvature of the spine. There are differing types of the condition. Mild-to-moderate curvatures can be managed by a brace. The brace is worn daily for all activities other than bathing. Clients should remove the brace for only 1 hour each day. Exceeding this time with the brace off will impair the therapeutic effects of the bracing treatment. During the time the brace is off, hygiene activities such as bathing should be done. It is important to check the brace for any damage daily to prevent injury. For comfort, a lightweight t-shirt may be worn under the brace.

The child has been diagnosed with rickets. The child's mother is educated about the importance of providing the child with 10 micrograms (400 International Units) of an oral vitamin D supplement each day. The child's mother purchases over-the-counter vitamin D drops. The supplement is noted to contain 5 mcg of vitamin D in each 0.5 mL. How much of the supplement should the mother administer to the child each day? Record your answer using one decimal place.

1 The supplement has 5 mcg of vitamin D in each 0.5 mL. The child is supposed to receive 10 mcg each day of supplemental vitamin D. Desired/Have x Quantity = dose 10 mcg/5 mcg x 0.5 mL = 1.0 mL Ratio/proportion: 0.5 mL/5 micrograms = x/10 micrograms = 1.0 mL

A nurse is providing care to a child diagnosed with cerebral palsy who is experiencing painful muscle spasms. The health care provider has prescribed baclofen 40 mg/day PO in three divided doses. How many milligrams should the nurse administer in each dose? Record your answer using one decimal place.

13.3 The nurse will divide the number of doses per day into the total amount prescribed for each day. 40 mg ÷ 3 doses = 13.3 mg/dose

The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse in which situation?

A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. Spiral fractures, which twist around the bone, are frequently associated with child abuse and are caused by a wrenching force. When a broken bone penetrates the skin, the fracture is called compound, or open. A simple, or closed, fracture is a single break in the bone without penetration of the skin. In a greenstick fracture, the bone bends and often just partially breaks.

A nurse who is discussing Duchenne muscular dystrophy characterizes it correctly using which descriptors?

Duchenne muscular dystrophy causes progressive muscular weakness that ends in death Duchenne muscular dystrophy is the most common of several muscular dystrophies and is a progressive, fatal disorder. It involves mainly skeletal muscles, but other muscles are affected over time. Onset occurs in early childhood. The disorder is X-linked recessive. An enzyme is lacking that is necessary for the maintenance of muscle cells. No structural abnormalities of the spinal cord or peripheral nerves are noted.

The nurse is observing a 3-year-old boy who is sitting and playing in the waiting area of his pediatrician's office. The nurse calls the boy and his mother back for the boy's appointment. The boy rolls onto his stomach and pushes himself to his knees. Then he presses his hands against his ankles, knees, and thighs, walking up the front of his body, to stand. Which condition should the nurse suspect in this client?

Duchenne's muscular dystrophy By age 3, children with Duchenne muscular dystrophy can rise from the floor only by rolling onto their stomachs and then pushing themselves to their knees. To stand, they press their hands against their ankles, knees, and thighs (they "walk up their front"); this is a Gower sign. Symptoms of facioscapulohumeral muscular dystrophy begin after the child is 10 years old, and the primary symptom is facial weakness. The child becomes unable to wrinkle the forehead and cannot whistle. Congenital myotonic dystrophy begins in utero and typically leads to death before age 1 year because of inability to sustain respiratory function. The symptoms of juvenile arthritis are primarily stiff and painful joints.

The school nurse cares for children with overuse injuries and refers them for treatment. Which statements accurately describe conservative interventions to prevent or care for these types of injuries? Select all that apply.

Encourage 1 to 2 days off per week of competitive athletics. Apply ice to the injured area to reduce inflammation. Perform appropriate stretching during a 20-to 30-minute warmup Conservative treatment methods for the child with an overuse injury include encouraging 1 to 2 days off per week of competitive athletics, performing appropriate stretching during a 20-to 30-minute warmup, and applying ice to the injured area to reduce the inflammation and irritation. NSAIDs (ibuprofen) are used for inflammation and pain control. The physical therapist institutes a stretching and strengthening program for the appropriate muscle groups. Parents and coaches may not understand that the level of activity that causes overuse symptoms varies from child to child. Notes or telephone conversations from the physician or nurse to the child's coach can clarify any misconceptions about what is expected during the recovery and recuperative periods.

The nurse is caring for an 11-year-old presenting with tenderness in the shoulder. He is the pitcher for his baseball team and reports shoulder pain with active internal rotation but is able to continue past the pain with full range of motion. Based on these reported symptoms, the nurse is aware that the disorder is most likely to be:

Epiphysiolysis of the proximal humerus Epiphysiolysis of the proximal humerus is an overuse disorder that occurs with rigorous upper extremity activity such as pitching and causes tenderness in the shoulder. Osgood-Schlatter disease causes knee pain and painful swelling or prominence of the anterior portion of the tibial tubercle. Sever disease causes pain over the posterior aspect of the calcaneus. Epiphysiolysis of the distal radius is an overuse disorder that causes wrist pain. It is common in gymnasts.

The nurse is conducting a physical examination of a 10-year-old boy with a suspected neuromuscular disorder. Which finding is a sign of Duchenne muscular dystrophy?

Gower's sign A sign of Duchenne muscular dystrophy (DMD) is Gowers sign, or the inability of the child to rise from the floor in the standard fashion because of weakness. Signs of hydrocephalus are not typically associated with DMD. Kyphosis and scoliosis occur more frequently than lordosis. A child with DMD has an enlarged appearance to their calf muscles due to pseudohypertrophy of the calves.

A nurse is providing care to parents whose infant has been diagnosed with spinal muscular atrophy (SMA) type 1. The parents ask the nurse to explain what this diagnosis means for their child long term. Which statement should the nurse include in the explanation?

Muscular wasting results in generalized immobility and difficulty feeding and breathing. SMA type 1 is the most severe form of spinal muscle atrophy that results in muscle wasting, generalized immobility and difficulty feeding. This is an autosomal recessive genetic disorder that affects motor but not cognitive development. SMA type 1 has a rapid progression; these infants do not usually live past 2 years of age. Infants diagnosed with SMA type 1 will not sit unassisted and will not walk. Physical therapy is beneficial in strengthening some muscles, especially in those with the less severe SMA types 2, 3 or 4.

The nurse is assessing a preadolescent client reporting pain and swelling just below the knee. The client states it hurts worse after running. What treatment would the nurse expect to be prescribed for this client?

NSAIDs, ice, and limiting exercise The child's symptoms suggest Osgood-Schlatter disease, which is a thickening and enlargement of the tibial tuberosity probably from overuse. Treatment includes administration of NSAIDS, ice, and limiting strenuous activity. Ankle and knee strengthening exercises, applications of ice, and use of acetaminophen is not indicated for this disorder.

An emergency room nurse prepares a pamphlet to use as a teaching tool for the proper care of sprains. What information might be included in this guide? Select all that apply.

Promote early motion after acute injury of the soft tissue. Perform quadriceps and hamstring exercises for knee sprains. Perform ROM exercises for ankle and wrist injuries. Wrap the extremity starting distal from the affected area. Early motion after acute injury of the soft tissue will help the child make a more rapid recovery. Physical therapists instruct the client in quadriceps and hamstring exercises for knee sprains and strains. For ankle and wrist injuries, a ROM program is implemented. In grade I and II ankle sprains, rehabilitation can begin immediately; prolonged immobilization is not recommended. When walking with crutches, the child should bear weight on the hands (not the underarms) to avoid nerve damage. Wrapping the injury should be started distal from the affected area.

A nurse has provided care to several children during their well-child visits. The nurse has assessed each child's neurologic status. Which assessment finding indicates a problem requiring intervention?

a 4-year-old preschool age child who consistently walks on tip of toes At 4 years of age, a child should not consistently walk on tip toes. This is common manifestation of *muscular dystrophy* and requires intervention. At 2 months of age, an infant's movements are uncoordinated and may take several attempts to touch objects the infant reaches for. Infants begin to walk between 9 and 18 months of age, and may begin by walking while holding a caregiver's hands. At 2 years of age, a toddler is able to walk up the steps one step at a time.

A group of students are reviewing information about bone healing in children. The students demonstrate understanding of this information when they state:

a child's bones heal more quickly than those of an adult Bone healing occurs in the same fashion as in the adult, but it occurs more quickly in children because of the rich nutrient supply to the periosteum. The closer a fracture is to the growth plate, the more quickly the fracture heals. The capacity for remodeling (the process of breaking down and forming new bone) is increased in children compared with adults. Children's bones produce callus more rapidly and in larger quantities than do adults' bones.

How would the nurse best describe Gowers sign to the parents of a child with muscular dystrophy?

a transfer technique Gowers' sign is a description of a transfer technique present during some phases of muscular dystrophy. The child turns on the side or abdomen, extends the knees, and pushes on the torso to an upright position by walking his hands up the legs. The child's gait is unrelated to the presence of Gowers sign. Muscle twitching present after a quick stretch is described as clonus.

The nurse is caring for an 8-month-old infant in Bryant traction for developmental dysplasia of the hip (DDH) and is monitoring for complications. Which assessment finding most concerns the nurse?

a weak pedal pulse A diminished pedal pulse could be a sign of neurovascular compromise caused by pressure from the elastic bandages. Decreased oral intake and an elevated temperature could indicate an infection. However, circulation is priority over infection in the client and would be most concerning for the nurse. Mild fussiness is to be expected and is nonspecific when an infant is immobilized and has both legs extended vertically.

Which client would be the most likely person to be diagnosed with idiopathic scoliosis that requires treatment?

a young adolescent female Mild scoliosis occurs between the genders equally, but idiopathic scoliosis requiring treatment occurs 10 times more often in females than males. Usually, treatment is initiated during early adolescence, around age 11 to 14 years.

A group of students are reviewing information about the skeletal development in children. The students demonstrate understanding of the information when they identify that ossification is complete by what age?

adolescents Ossification and conversion of cartilage to bone continue throughout childhood and are complete at adolescence.

Why will it be necessary for the nurse to be very supportive of parents' attempts to feed the infant with recently repaired myelomeningocele?

assuming the usual feeding position will be difficult Because the repaired area will need to be protected, having to use an alternate feeding position is likely. The infant may need to be fed prone with the head turned to the side and may not be able to be held. Being able to provide food for the infant is central to parenting the child. Difficulty nurturing a child can be very stressful. Little pain will be experienced and should easily be controlled owing to loss of sensation in the area. The sucking reflex should not be affected by the myelomeningocele or its repair. Nausea and vomiting are unlikely after recovery from the anesthetic.

In understanding the development of the musculoskeletal system, the nurse recognizes that what is implanted in a gel-like substance during fetal life?

cartilage During fetal life, tissue called cartilage, which is a type of connective tissue consisting of cells implanted in a gel-like substance, gradually calcifies and becomes bone.

A child is born with clubfoot (congenital talipes equinovarus). The child later receives a cast on the affected leg to correct the problem. Which measure should the nurse mention to the mother to ensure good circulation in the affected leg?

check the infants toes for coldness or blueness Review with parents how to check the infant's toes for coldness or blueness and how to blanch a toenail bed and watch it turn pink to assess for good circulation. The other answers are other interventions pertaining to caring for a child with clubfoot but are not associated specifically with ensuring good circulation.

The nurse caring for a client diagnosed with muscular dystrophy would expect which laboratory values to be most abnormal?

creatinine kinase Serum creatine kinase levels are elevated early in the disorder, when significant muscle wasting is actively occurring. Bilirubin is a by-product of liver function. Potassium and sodium levels can change due to various factors and aren't indicators of muscular dystrophy.

The nurse is planning to teach the parents of a child with newly diagnosed muscular dystrophy about the disease. Which definition should she use to best describe this condition?

degeneration of muscle fibers Degeneration of muscle fibers with progressive weakness and wasting best describes muscular dystrophy. Demyelination of myelin sheaths is a description of multiple sclerosis. Lesions within the brain cortex and the upper motor neurons suggest a neurologic, not a muscular, disease.

The nurse is caring for a 10-year-old girl in traction. The girl is experiencing muscle spasms associated with the traction. What would the nurse expect to administer if ordered?

diazepam Diazepam is an antianxiety drug that also has the effect of skeletal muscle relaxation; it is used for the treatment of muscle spasm associated with traction or casting. Narcotic analgesics are used for pain relief. Alendronate increases bone mineral density for children with osteogenesis imperfecta. Pamidronate increases bone mineral density for children with osteogenesis imperfecta.

The nurse is assessing a 10-year-old girl recently fitted with a cast on her wrist. Which assessment finding would alert the nurse to a possible infection?

draining on the cast Drainage on the cast could indicate an infection. Pale fingers, delayed capillary refill, and diminished pulse would suggest impaired circulation.

The nurse caring for a client in a body cast knows that immobility can cause contractures, loss of muscle tone, or fixation of joints. Which nursing interdisciplinary intervention is recommended to help prevent these adverse conditions?

encourage active and passive range of motion activities to prevent ineffective tissue perfusion The nurse should turn the client and encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. The client should be instructed to cough and breathe deeply to prevent respiratory complications. Normal capillary refill is 1 to 3 seconds. The client should be given small, frequent meals with increased fiber, protein, and vitamin C to prevent malnutrition.

The nurse caring for a child who has been put into a leg cast must be on the alert for signs of nerve and muscle damage. Which symptom might be an early warning signal that the child has developed compartment syndrome? The child:

feels increasing severe pain Any reports of pain in a child with a new cast or immobilized extremity need to be explored and monitored closely for the possibility of compartment syndrome.

A nurse is conducting a physical examination of an infant with suspected metatarsus adductus. Type II metatarsus adductus is indicated when the forefoot is:

flexible passively past neutral, but only to midline actively In type II metatarsus adductus, the forefoot is flexible passively past neutral, but only to midline actively. The forefoot is flexible past neutral actively and passively in type I. The forefoot is rigid, does not correct to midline even with passive stretching in type III. An inverted forefoot turned slightly upward is indicative of clubfoot.

The nurse is caring for a child who has just had a plaster cast applied to the arm. The nurse is correct in performing which action with this child?

handling the cast with open palms when moving the arm A wet plaster cast should be handled only with open palms because fingertips can cause indentations and result in pressure points. There is no reason the arm should be restrained or the arm moved to aid in the drying process.

Through which mechanism is Duchenne muscular dystrophy acquired?

heredity Muscular dystrophy is hereditary and acquired through a recessive sex-linked trait. Therefore, it isn't caused by viral, autoimmune, or environmental factors.

The nurse is obtaining a health history on a woman of childbearing age who wants to become pregnant. What information in her health history places her at high risk for having a child with a myelomeningocele?

history of a seizure disorder; taking phenobarbital Maternal consumption of certain drugs that antagonize folic acid, such as anticonvulsants (carbamazepine and phenobarbital), places her at high risk for having a child with neural tube defect such as a myelomeningocele. A history of taking montelukast, previous abdominal surgery, or a history of scoliosis do not pose a risk for having a child with a myelomeningocele.

A 5-year-old child is in traction and at risk for impaired skin integrity due to pressure. Which intervention is most effective?

inspect the child's skin for rashes, redness, irritation, or pressure sores It is important to be vigilant in inspecting the child's skin for rashes, redness, and irritation to uncover areas where pressure sores are likely to develop. Applying lotion is part of the routine skin care regimen. Applying lotion, gentle massage, and keeping skin dry and clean are part of the routine skin care regimen.

Which characteristic is true of cerebral palsy?

it appears at birth or during the first 2 years of life Cerebral palsy is an irreversible, nonprogressive disorder that results from damage to the developing brain during the prenatal, perinatal, or postnatal period. Although some children with cerebral palsy are intellectually disabled, many have normal intelligence.

The nurse will teach parents of children with myelomeningocele to maintain an environment free of what element?

latex A latex-free environment is important because research shows that up to 73% of children with repeated surgeries for spina bifida are sensitive to latex. Those with known sensitivity must be managed in a latex-free environment in the health care setting and in the home, in the school, and beyond. Children at risk for latex sensitivity should wear medical alert identification. The other options may present risks to individual children but are not a threat to those with spina bifida as a group.

Which of these strategies would be the first choice in attempting to maximize function in a child with muscular dystrophy?

long leg braces Long leg braces are functional assistive devices that provide increased independence and increased use of upper and lower body strength. Wheelchairs, both motorized and manual, provide less independence and less use of upper and lower body strength. Walkers are functional assistive devices that provide less independence than braces.

The nurse caring for a client with suspected muscular dystrophy would prepare her client for which diagnostic test?

muscle biopsy Muscle biopsy provides definitive diagnosis of muscular dystrophy demonstrating the absence of dystrophin. X-ray is best for identifying an osseous deformity. Ambulation assessment alone wouldn't confirm diagnosis of this client's disorder. EEG wouldn't be appropriate in this case.

The nurse is caring for a child who had a cast on his lower leg placed two hours ago. When assessing the child's foot, the nurse notes that the toes are cool and the child reports extreme pain. What is the best action by the nurse?

notify the healthcare provider of the findings immediately Cool fingers or toes, extreme pain, and impaired movement are symptoms of compartment syndrome. Compartment syndrome can severely decrease blood flow to the area causing damage and necrosis to the surrounding area. If compartment syndrome occurs, the cast needs to be released immediately; therefore, the health care provider must be notified of these assessment findings immediately. Administration of pain medication, positioning, and ice are interventions that may be prescribed after a cast is placed, but they are not the first treatment for compartment syndrome.

The nurse is caring for an infant with myelomeningocele prior to having repair surgery. What nursing intervention(s) is necessary to include in this infant's plan of care? Select all that apply.

positioning of paralyzed legs to prevent contractures protecting knees and elbows from skin breakdown keeping the skin clean and dry A myelomeningocele is a spinal cord defect. The sac protrudes through the skin. The spinal cord ends at the level of the defect causing no motor or sensory function below that point. The infant must remain in a prone position to keep from causing damage to the sac until repair can be done. This also means no diapers. Skin integrity and positioning are essential. This infant could have breakdown on the knees and elbows and even the side of the head. The infant needs to be cleaned regularly and kept dry. Different types of mattresses can be used to reduce pressure on bony prominences. The paralyzed lower extremities need to be repositioned regularly to prevent contractures. A high-calorie, concentrated formula is not necessary. Regular-calorie formula is adequate. A pacifier for nonnutritive sucking is a good idea and may be a comfort to the infant, but it is not essential.

A nurse is providing care to a pediatric client hospitalized with a diagnosis of Duchenne muscular dystrophy (DMD). The nurse is reviewing the above laboratory results. Which laboratory result will have the greatest impact on the client's condition?

potassium The potassium level is low and will have the greatest impact on the client's condition. Children diagnosed with DMD often have issues with cardiac and respiratory function and are often on antihypertensive and diuretic medications. They will also be prescribed glucocorticoids to manage the neuromuscular effects of the disorder. The glucose level is elevated slightly and will need to be monitored especially in the presence of glucocorticoids but the potassium level requires immediate intervention. The creatinine and calcium levels are within normal limits.

The nurse is conducting a physical examination of a 9-month-old infant with a suspected neuromuscular disorder. Which finding would warrant further evaluation?

presence of Moro reflex The persistence of a primitive reflex in a 9-month-old would warrant further evaluation. Symmetrical spontaneous movement and absence of the Moro and tonic neck reflex are expected in a normally developing 9-month-old child.

The nurse is caring for a child with a broken wrist that has just been placed in a cast. The nurse would elevate the arm to:

prevent edema Edema tends to be dependent. Elevating the arm, therefore, would reduce swelling from the injury. Elevation of the arm would not promote healing or discourage infection. The cast will maintain proper bone alignment.

A nurse is preparing a plan of care for an infant who has undergone surgery to repair a myelomeningocele. The nurse would include placing the infant in which positions postoperatively? Select all that apply.

prone left side lying right side lying Postoperatively, the nurse would position the infant in the prone or side-lying position to allow the incision to heal.

A parent brings an 18-month-old child to the pediatrician's office for a well-child visit. The child has mild cerebral palsy that affects the child's gait. The nurse wants to assess the child's neuromuscular system. What is the best way for the nurse to make that assessment?

quietly observe the child at play while interviewing the parent The best way to assess a young child's neuromuscular system is to observe the child from a distance. Observing the child at play will allow the nurse to assess the child's gross and fine motor skills, as well as cognitive abilities. Asking the parent to describe the child's motor development may be appropriate in some cases such as the ability to feed. Getting down to the child's level may help assess the child's social development but observing the child play at a distance is best to assess a child's fine and gross motor development. Reviewing the child's history will give the nurse a sense of the child's past developmental level but will not give information about the child's current status.

Which nursing diagnosis will the nurse prepare for the infant who is placed prone to protect the myelomeningocele repair site?

risk for impaired skin integrity The skin of the infant's knees and elbows is exposed to both pressure and friction. Leakage of urine and stool makes skin cleanliness a challenge. Should voluntary movement of the legs be affected, they become more vulnerable to skin integrity problems. The neuromuscular dysfunction the infant experiences is neither peripheral nor vascular. Disorganized infant behavior does not reflect the reality of the situation, and risk for activity intolerance is not appropriate because little activity occurs.

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele?

risk for infection All of these diagnoses are important for a child with a myelomeningocele. However, during the first 12 hours of life, the most life-threatening event would be an infection. The other diagnoses will be addressed as the child develops.

The nurse is caring for a 2-year-old boy with cerebral palsy (CP). The medical record indicates "hypertonicity and permanent contractures affecting both extremities on one side." Based on these findings, the nurse identifies this type of CP as:

spastic Spastic involves hypertonicity and permanent contractures on both extremities on one side. Athetoid (dyskinetic) involves abnormal involuntary movements affecting all four extremities and sometimes the face, neck, and tongue. Ataxic affects balance and depth perception. Spastic affects the lower extremities. Mixed is a combination of spastic, athetoid and ataxic.

The nurse is discussing types of treatment used when working with children who have orthopedic disorders. Which form of treatment covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open?

spica cast The hip spica cast covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open. The cast maintains the legs in a frog-like position. Usually, there is a bar placed between the legs to help support the cast.

Which type of spinal neural tube defect does the nurse recognize as common and usually benign?

spinal bifida occulta Spina bifida occulta usually is benign and is estimated to affect 10% to 20% of the population. It is a defect in the vertebral body without protrusion of the spinal cord or its coverings. Spina bifida is a general term that is often used to refer to all neural tube disorders of the spinal cord. Meningocele and myelomeningocele do involve protrusion of elements of the spinal portion of the central nervous system and require treatment.

A nurse is assessing a newborn and observes webbing of the fingers and toes. The nurse documents this finding as:

syndactyl Syndactyly refers to webbing of the fingers and toes. Polydactyly refers to the presence of extra digits on the hand or foot. Metatarsus adductus is a medial deviation of the forefoot. Pectus carinatum is a protuberance of the chest wall.

In caring for a child in traction, which intervention is the highest priority for the nurse?

the nurse should monitor for decreased circulation every 4 hours Any child in traction must be carefully monitored to detect any signs of decreased circulation or neurovascular complications. Cleaning pin sites is appropriate for a child in skeletal traction to reduce the risk of infection. Providing age-appropriate activities and monitoring intake and output are important interventions for any ill child but would not be the highest priority interventions for the child in traction.

An adolescent wears a body brace for scoliosis. Which client education should the nurse provide?

to continue with age appropriate activities The treatment for scoliosis is aimed at preventing progression of the curve and decreasing the impact on the pulmonary and cardiac function. Bracing is one way to do that. The brace should be worn for 23 hours per day. Wearing a body brace should not interfere with normal activities, which are necessary to maintain adolescent self-esteem. It is extremely important that the adolescent has compliance with the brace usage. The nurse can help by teaching the adolescent ways to help peers understand the need for the brace. Sex changes continue with or without bracing.

The nurse is caring for a 3-year-old boy with a fracture of the humerus. His chart indicates "fracture is partially through the physis extending into the metaphysis." The nurse identifies this as which Salter-Harris classification?

type II According to the Salter-Harris classification, a type II fracture is partially through the physis extending into the metaphysis. A type I fracture is through the physis, widening it. A type IV fracture is through the metaphysis, physis, and epiphysis. A type V fracture is a crushing injury to the physis.

The charge nurse is observing a student nurse perform skeletal traction pin care. What action by the student nurse would indicate a need for intervention by the charge nurse?

unhooking a weight while providing skin care Weights should never be moved or unhooked during skeletal traction. Pin care is a sterile procedure. Pins are cleaned with half-strength hydrogen peroxide and then typically covered with sterile cotton gauze.

A client with muscular dystrophy has lost complete control of his lower extremities. He has some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair?

wheelchair belt This client has poor trunk control; a belt will prevent him from falling out of the wheelchair. Antitip devices, head rest supports, and extended breaks are all important options but aren't the most important options in this situation.

The nurse is caring for a child diagnosed with Duchenne muscular dystrophy and notes the presence of a Gower sign on the assessment form. What action by the child would support this assessment?

when on the floor, rising to the knees and pressing the hands against the ankles, knees, and thighs to stand A Gower sign is when children "walk up their front." When on the floor, the only way they can stand is to roll on their stomach and push themselves up to their knees. They then press their hands against their ankles, knees, and thighs. The presence of a waddling gait, difficulty climbing stairs, and a short heel cord are all present in Duchenne muscular dystrophy, but they are not the Gower sign. Meeting milestones late is also a symptom of this disorder, but it is not the Gower sign.