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?
Monitor the capillary refill of the toes.
Compare the temperature of both legs.
Observe for spontaneous movement.
Check the femoral pulses.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While protein is an essential nutrient for overall health and wellbeing, increasing protein intake alone is unlikely to significantly improve hemoglobin levels. Hemoglobin is a protein in red blood cells that carries oxygen, and its production depends on having enough iron, vitamin B12, and folic acid, not just protein.
Choice B rationale
During pregnancy, the volume of blood in a woman’s body increases to support the growing fetus. This increase in blood volume can dilute the blood, which can lead to a decrease in the concentration of red blood cells and hemoglobin, a condition known as physiological anemia of pregnancy. This is a normal part of pregnancy and is typically not a cause for concern.
Choice C rationale
While it’s true that many women experience changes in their hemoglobin levels during pregnancy, it’s not accurate to say that almost all women at 28-weeks gestation have anemia. Anemia is defined as a level of hemoglobin that’s lower than normal, and the normal range can vary. However, it’s important to note that the normal range for hemoglobin does decrease during pregnancy.
Choice D rationale
Iron is a key component of hemoglobin, and iron deficiency is a common cause of anemia. If a pregnant woman’s hemoglobin levels are low, taking an iron supplement might help increase these levels. However, it’s important to talk to a healthcare provider before starting any new medication or supplement.
Correct Answer is D
Explanation
Choice A rationale
Placing a pulse oximeter on the heel of a newborn can help monitor oxygen saturation levels. However, the symptoms described, such as jitteriness, hypotonicity, and a weak cry, are more indicative of hypoglycemia, a condition that would not be detected by a pulse oximeter.
Choice B rationale
Swaddling the infant in a warm blanket can help maintain body temperature, but it does not address the underlying cause of the symptoms, which are suggestive of hypoglycemia.
Choice C rationale
Documenting the findings in the record is an important part of nursing care, but it does not provide immediate intervention for the symptoms observed.
Choice D rationale
Obtaining a heel stick blood glucose level is the appropriate action given the symptoms described. Jitteriness, hypotonicity, and a weak cry can be signs of neonatal hypoglycemia. Prompt diagnosis and treatment are essential to prevent potential complications.
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