The nurse is caring for a child with a unilateral long-leg cast applied for the correction of clubfoot. Which action is most important for the nurse to perform?

Compare the temperature of both legs.

Monitor capillary refill of the toes.

Examine for spontaneous movement.

Palpate femoral pulses.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Comparing the temperature of both legs can help identify potential circulatory issues or infections. However, temperature differences are not the most immediate concern when assessing a child with a long-leg cast. Monitoring neurovascular status, including circulation and nerve function, is more critical to ensure there are no complications such as compartment syndrome or impaired blood flow.

Choice B rationale

Monitoring capillary refill of the toes is crucial for assessing the circulatory status of the affected limb. Capillary refill time indicates how well blood is perfusing to the extremities. A delayed capillary refill time can suggest compromised circulation, which could lead to serious complications like tissue ischemia. This assessment helps ensure that the cast is not too tight and that there is adequate blood flow to the toes.

Choice C rationale

Examining for spontaneous movement is important for assessing motor function and ensuring that there is no nerve damage. However, it is not as immediate a concern as circulatory assessment. Spontaneous movement can indicate intact motor function, but circulatory compromise would need to be addressed urgently to prevent tissue damage.

Choice D rationale

Palpating femoral pulses is important for assessing the overall circulation to the lower extremities. However, in the context of a long-leg cast, it is more relevant to directly assess the area distal to the cast (such as the toes) for adequate perfusion. Checking femoral pulses alone does not provide specific information about potential compartment syndrome or tightness of the cast affecting distal circulation.

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Correct Answer is A

Explanation

Choice A rationale

Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.

Choice B rationale

Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.

Choice C rationale

Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.

Choice D rationale

Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .

A. These findings are within normal limits and require routine follow-up. B. All findings are outside of the acceptable range and should be reported to the healthcare provider immediately. C. The primary IV fluids should be increased to assist in increasing the urinary output. D. The findings indicate potential toxicity to the magnesium sulfate and close follow-up is indicated.

Correct Answer is B

Explanation

Choice A rationale

While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.

Choice B rationale

Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.

Choice C rationale

Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.

Choice D rationale

The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.

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The nurse is caring for a child with a unilateral long-leg cast applied for the correction of clubfoot. Which action is most important for the nurse to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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