Which assessment finding for a toddler-age child in balanced Bryant traction for a fractured right femur would require immediate action by the nurse?
1. The child keeps trying to turn and lie on his belly.
2. The ropes are unequal in length.
3. The child's buttocks are resting on the bed.
4. The Ace bandage wrapping the legs is wrinkled.
3
Explanation:
1. This child needs a jacket restraint to maintain appropriate positioning if someone cannot stay with him. It does not require notifying the surgeon.
2. In balanced traction, the ropes and pulleys determine the traction and the length of the rope is unimportant.
3. In order to provide adequate counter-traction, the buttocks should be slightly elevated off the bed. The surgeon should be notified.
4. This is not a significant finding.
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