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 B

Explanation

Choice A reason: Developing friendships is important, but it is not as critical as walking in the early stages of a toddler's development.
Choice B reason: This is the correct choice. Walking is a significant developmental milestone for toddlers and is essential for their physical autonomy.
Choice C reason: Self-feeding is an important skill, but it typically develops after the child has learned to walk.
Choice D reason: Potty-training is a key milestone, but it usually occurs after the child has achieved the ability to walk.

A. Risk for Altered Tissue Perfusion B. Impaired Physical Mobility C. Risk for Altered Nutrition: Less than Body Requirements D. Risk for Fluid Imbalance

Correct Answer is A

Explanation

Choice A reason: A third-degree circumferential burn can compromise blood flow, posing an immediate risk for altered tissue perfusion, which can lead to tissue necrosis and limb loss.

Choice B reason: While impaired physical mobility is a concern, it is not as immediately life-threatening as altered tissue perfusion.

Choice C reason: Nutritional needs are important for healing, but the immediate threat to life from a third-degree burn is the risk for altered tissue perfusion.

Choice D reason: Fluid imbalance is a significant concern due to the potential for burn-induced edema and dehydration; however, the most immediate life-threatening issue is altered tissue perfusion.

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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

Naxlex Comprehensive Predictor Exams

According to developmental theories, which important event is essential in the development of the toddler?

Correct Answer is B

Explanation

What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?

Correct Answer is A

Explanation

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