A nurse is providing care for an infant with new casts for the treatment of club foot. Which intervention is appropriate in promoting the infant's comfort and preventing complications?

Elevating the legs on a pillow

Applying heat therapy to the casted area

Removing the casts periodically for bathing

Encouraging the infant to crawl and bear weight on the affected leg

Answer and Explanation

The Correct Answer is A

A.   Elevating the legs on a pillow helps reduce swelling and discomfort while the cast is healing.
B.   Heat therapy should not be applied to the casted area, as it could cause skin irritation or burns.
C.   Casts should not be removed for bathing unless specifically ordered by the provider.
D.   Encouraging the infant to crawl or bear weight on the affected leg is not appropriate until the cast is removed and healing is complete.

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Correct Answer is D

Explanation

A. While pain management is important, the priority is assessing for complications that could arise after the procedure.
B. Discharge teaching is important, but the priority immediately after the procedure is monitoring for complications.
C. While hydration is important, it is not the immediate priority following VP shunt placement, where the focus should be on assessing for signs of complications.
D. Regular monitoring of vital signs is crucial to detect complications such as shunt malfunction, infection, or increased intracranial pressure.

A. Administer morphine sulfate to help alleviate pain and anxiety. B. Provide supplemental oxygen via nasal cannula. C. Offer the infant a pacifier to calm down. D. Place the infant in a knee to chest position.

Correct Answer is D

Explanation

A. While morphine can help to relieve anxiety and pain, it does not address the underlying cause of a hypercyanotic spell, which is the right-to-left shunting. The first step should be positioning the infant properly.
B. Although oxygen is helpful, it will not be as effective as using the knee-to-chest position to alleviate the underlying circulatory issue causing the hypercyanotic spell.
C. While comforting the child is important, a pacifier will not help in alleviating the hypercyanotic spell and is not the primary intervention in this emergency situation.
D. In a hypercyanotic spell, the priority is to increase systemic vascular resistance to decrease the right- to-left shunting of blood. The knee-to-chest position is effective for this, as it increases the resistance in the lower extremities, helping to improve oxygenation.

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A nurse is providing care for an infant with new casts for the treatment of club foot. Which intervention is appropriate in promoting the infant's comfort and preventing complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

Correct Answer is D

Explanation

A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry. What is the priority nursing action for this Infant?

Correct Answer is D

Explanation

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