What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired? Select all that apply.
Observe for skin irritation.
Keep cast uncovered to allow drying.
Assess color of toes.
Check toes for capillary refill.
Keep casted leg lowered.
Correct Answer : A,B,C,D
The correct answer is A, B, C, and D. After a clubfoot repair surgery, the plan of care should include observing for skin irritation, keeping the cast uncovered to allow drying, assessing the color of toes, and checking toes for capillary refill. Keeping the casted leg lowered is not recommended as it can lead to swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The FACES pain scale is typically used for children who are at least 3 years old. It requires the child to compare their pain to a series of faces ranging from smiling to crying.
Choice B rationale
The Word-Graphic Rating Scale is typically used for older children and adolescents who can read and understand the descriptive words associated with each level of pain.
Choice C rationale
The FLACC pain scale, which stands for Face, Legs, Activity, Cry, and Consolability, is appropriate for assessing pain in a 3-month-old infant. It is often used for children under 3 years old or those who are unable to verbally communicate their pain.
Choice D rationale
The Oucher pain scale is typically used for children aged 3 to 13 years. It includes a series of photographs of children’s faces and a numerical scale for older children.
Correct Answer is B
Explanation
Choice A rationale
Measuring from the back of the head to the forehead is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice B rationale
Placing the measuring tape above the eyebrows and around the widest part of the head is the correct method for measuring head circumference in an infant. The tape should be wrapped around the head at the points just above the eyebrows, above the ears, and around the back where the head slopes up prominently from the neck.
Choice C rationale
Measuring from the chin to the top of the head is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice D rationale
Wrapping the measuring tape tightly around the neck is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
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