After surgery for the correction of bilateral congenital clubfeet, an infant returns with bilateral long-leg casts. The toes on both feet are edematous, yet there is color, sensitivity, and movement. What is the most appropriate action by the nurse?
Apply a warm, moist pack to the feet.
Call the healthcare provider to report the edema.
Elevate the legs on pillows.
Encourage movement of the toes.
The Correct Answer is C
Choice A reason: Applying a warm, moist pack is not the most appropriate action as it may increase swelling and does not address the underlying cause of the edema.
Choice B reason: While it is important to report significant changes to the healthcare provider, mild edema post-surgery can be expected and managed with elevation.
Choice C reason: Elevating the legs on pillows can help reduce edema by promoting venous return and decreasing swelling.
Choice D reason: Encouraging movement of the toes is beneficial for circulation and preventing stiffness, but it is not the primary intervention for edema. Elevation is more effective in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is correct; early treatment for clubfoot is essential for the best outcomes.
Choice B reason: The parent's understanding of the need for long-term follow-up care until skeletal maturity is accurate.
Choice C reason: Regular visits for new casts are part of the standard treatment protocol for clubfoot.
Choice D reason: This statement indicates a misunderstanding. Clubfoot treatment typically involves a series of casts changed more frequently than 8-10 weeks apart, not a single spica cast for that duration. Further teaching is needed to correct this misconception.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. There is no need for the mother to leave the room unless the child requests privacy.
Choice B reason: This choice is incorrect. While reviewing health promotion is important, it should not be the focus during a sick visit.
Choice C reason: This choice is incorrect. A comprehensive history is not necessary if the child is regularly seen and was recently assessed.
Choice D reason: This is the correct choice. The nurse should focus on the current illness reported by the mother, as the child has been regularly seen and assessed.
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