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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is not accurate and may cause unnecessary distress, as Guillain-Barré Syndrome often does not result in a lifelong prognosis.
Choice B reason: This statement is overly optimistic and may not be accurate, as recovery times can vary greatly between individuals.
Choice C reason: This response provides a realistic expectation without causing undue alarm, acknowledging the temporary nature of the paralysis and the potential duration of recovery.
Choice D reason: While sensory loss can occur, it is not guaranteed, and the focus should be on the respiratory paralysis and the recovery process.
Correct Answer is B
Explanation
Choice A reason: Discussing the child's previous history of injury is important, but it does not address the immediate concern of pain management.
Choice B reason: Consulting with a practitioner to determine safe analgesia options is crucial for managing pain while also monitoring the child's variable consciousness levels.
Choice C reason: While it is true that analgesia can mask neurological symptoms, it is essential to manage pain effectively, and the healthcare team can monitor for changes in consciousness.
Choice D reason: Teaching the family about specific medications like benzodiazepines is not the most immediate concern and should be left to the practitioner's discretion based on the child's condition. Pain management and safety are the priorities.
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