A 4-year-old child is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first?
a. Reposition the child and notify the practitioner.
b. Notify the practitioner of the changes noted.
c. Give the child medication to relieve the pain.
d. Chart the observations and check the extremity again in 15 minutes.
ANS: B
The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. This is an emergency condition. Pain medication should be given after the practitioner is notified. The findings should be documented with ongoing assessment.
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