The Nurse Performs a Neuromuscular Assessment of a Child Who

The nurse performs a neuromuscular assessment of a child who is in Russell's traction.Which assessment findings indicate the need for further intervention? (Select all that apply.)

A) A pain rating of 6 on an age-appropriate numeric pain rating scale
B) The child feels the distal part of the extremity when touched by the nurse.
C) The child does not have a significant amount of edema in the extremity.
D) The child has a capillary refill time of more than 3 seconds.
E) The child's toes are cold and appear dusky.