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The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot.
What is the most important action for the nurse to perform?

A.

Monitor the capillary refill of the toes.

B.

Compare the temperature of both legs.

C.

Observe for spontaneous movement.

D.

Check the femoral pulses.

Answer and Explanation

The Correct Answer is A

Choice A rationale 
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis. 
Choice B rationale 
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill. 
Choice C rationale 
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill. 
Choice D rationale 
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case. 
 


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Related Questions

Correct Answer is C

Explanation

Choice A rationale

Variance in blood pressure across extremities is not typically associated with ventricular septal defects (VSDs). VSDs are characterized by a hole in the heart that allows oxygen-rich blood to move back into the lungs instead of being pumped to the rest of the body.

Choice B rationale

Hypotension is not a common symptom of VSDs. Instead, these defects can cause increased blood pressure in the lungs due to the abnormal flow of blood.

Choice C rationale

Tachycardia, or a rapid heart rate, is a common symptom of VSDs, especially in cases where the defect is medium or large. This is because the heart needs to work harder to pump blood, leading to an increased heart rate.

Choice D rationale

While pulse oximetry readings within defined limits could be seen in small VSDs, in larger defects or those causing heart failure, oxygen saturation levels might be lower due to the abnormal circulation of blood.

Correct Answer is B

Explanation

Choice A rationale
While assessing parenting skills is important in general, in this specific situation, the parent has expressed a fear of needles which is preventing them from being able to administer the insulin injections. Therefore, assessing parenting skills would not directly address the issue at hand.
Choice B rationale
If the child is capable and comfortable with administering their own insulin injections, this could be a viable solution to the problem. It is not uncommon for children, especially those who are older or more mature, to take over the administration of their own insulin injections. Choice C rationale
Encouraging the parent to handle the needles may be helpful, but if the parent has a strong fear of needles, this may not be a feasible solution. It’s important to respect the parent’s fear and find alternative solutions.
Choice D rationale
Asking if there is someone else who can help with the injections could potentially be a solution, but it would depend on the family’s situation and whether there is another person who is willing and able to help.

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