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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Feeding the toddler is important, but it does not specifically address the development of autonomy or decision-making skills.

Choice B reason: Dressing the toddler is a necessary task, but it does not encourage the child's active participation or independence.

Choice C reason: Offering the toddler a choice of clothing allows the child to make decisions, fostering a sense of control and independence, which is developmentally appropriate and empowering for the toddler.

Choice D reason: Asking the toddler if he would like to take his medicine is a good practice to involve the child in their care, but it is not as impactful on development as offering choices that promote autonomy.

A. Limit water intake to prevent hyponatremia. B. Check blood glucose every 8-12 hours. C. Drink 8oz of apple or orange juice every hour. D. Always give scheduled insulin even if the child has no appetite.

Correct Answer is D

Explanation

Choice A reason: Limiting water intake is not recommended as adequate hydration is important, especially when sick.
Choice B reason: Checking blood glucose every 8-12 hours is not frequent enough; it should be monitored more often during illness.
Choice C reason: Drinking juice every hour is not necessary and could lead to hyperglycemia if not balanced with insulin.
Choice D reason: This is the correct choice. It is crucial to continue administering insulin as prescribed to manage blood glucose levels, even if the child is not eating as much.

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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?

Nursing Test Bank

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Correct Answer is D

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