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.

Choice A rationale

Edema in the palm of the hand is a sign of IV infiltration. IV infiltration occurs when IV fluids or medications leak into the surrounding tissues outside the intended vein. This can cause swelling or edema, which is a common sign of infiltration.

Choice B rationale

Absence of blanching at the insertion site is not necessarily an indication of an infiltration. Blanching (whitening of the skin) can occur due to various reasons, including pressure on the site or a reaction to the IV fluid or medication. However, it is not a definitive sign of infiltration.

Choice C rationale

Warmth around the insertion site is not a definitive sign of an infiltration. While warmth can occur due to inflammation or infection, it is not a specific sign of infiltration.

Choice D rationale

Blood in the IV tubing is not a definitive sign of an infiltration. While blood can back up into the IV tubing due to various reasons, including a blocked or kinked catheter, it is not a specific sign of infiltration.

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.