The nurse is caring for a child with a unilateral long-leg cast applied for the correction of clubfoot. Which action is most important for the nurse to perform?

Compare the temperature of both legs.

Monitor capillary refill of the toes.

Examine for spontaneous movement.

Palpate femoral pulses.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Comparing the temperature of both legs can help identify potential circulatory issues or infections. However, temperature differences are not the most immediate concern when assessing a child with a long-leg cast. Monitoring neurovascular status, including circulation and nerve function, is more critical to ensure there are no complications such as compartment syndrome or impaired blood flow.

Choice B rationale

Monitoring capillary refill of the toes is crucial for assessing the circulatory status of the affected limb. Capillary refill time indicates how well blood is perfusing to the extremities. A delayed capillary refill time can suggest compromised circulation, which could lead to serious complications like tissue ischemia. This assessment helps ensure that the cast is not too tight and that there is adequate blood flow to the toes.

Choice C rationale

Examining for spontaneous movement is important for assessing motor function and ensuring that there is no nerve damage. However, it is not as immediate a concern as circulatory assessment. Spontaneous movement can indicate intact motor function, but circulatory compromise would need to be addressed urgently to prevent tissue damage.

Choice D rationale

Palpating femoral pulses is important for assessing the overall circulation to the lower extremities. However, in the context of a long-leg cast, it is more relevant to directly assess the area distal to the cast (such as the toes) for adequate perfusion. Checking femoral pulses alone does not provide specific information about potential compartment syndrome or tightness of the cast affecting distal circulation.

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Correct Answer is A

Explanation

Choice A rationale

A sore throat, often due to Streptococcus pyogenes, is a significant precursor to acute rheumatic fever. The body’s immune response to the infection can attack its own tissues, leading to rheumatic heart disease if untreated.

Choice B rationale

Influenza is a viral infection and does not typically lead to acute rheumatic fever. While it can cause significant illness, its mechanism and sequelae are unrelated to those of rheumatic fever.

Choice C rationale

Chickenpox, caused by the varicella-zoster virus, presents with distinct symptoms like a vesicular rash and is not linked to rheumatic fever. It primarily affects the skin and nervous system, not the heart.

Choice D rationale

Mumps, a viral infection, mainly impacts the salivary glands and sometimes the pancreas and testes but is not associated with rheumatic fever. Its pathology differs from the immune-mediated damage seen in rheumatic fever.

Correct Answer is ["1500"]

Explanation

Step 1 is. (500 mL ÷ 20 min) × 60 min/hr = 1500 mL/hr. Answer: 1500 mL/hr.

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The nurse is caring for a child with a unilateral long-leg cast applied for the correction of clubfoot. Which action is most important for the nurse to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

Correct Answer is A

Explanation

The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for a client with preterm labor. The IV bag contains "Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.”. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

Correct Answer is ["1500"]

Explanation

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