To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

Compress the tissue around the ankles.

Observe plantar flexion and dorsiflexion.

Palpate the volume of the pedal pulses.

Stroke the soles and note toe movement.

Answer and Explanation

The Correct Answer is C

A. Compress the tissue around the ankles: Compressing the tissue around the ankles can assess for edema but does not provide direct information about arterial circulation.

B. Observe plantar flexion and dorsiflexion: Observing plantar flexion and dorsiflexion assesses motor function and muscle strength but does not directly assess arterial circulation.

C. Palpate the volume of the pedal pulses: Palpating pedal pulses is a direct method to assess arterial blood flow to the lower extremities. It provides information about the strength and quality of arterial circulation.

D. Stroke the soles and note toe movement: Stroking the soles and noting toe movement is the Babinski reflex test, which assesses neurological function, not arterial circulation.

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Correct Answer is C

Explanation

A. Contact social services for a temporary shelter. While contacting social services is important for the overall care of a homeless pregnant woman, it is not the immediate priority in the presence of placenta previa and vaginal bleeding.

B. Obtain a hemoglobin and hematocrit level. Assessing hemoglobin and hematocrit levels is important to evaluate the extent of blood loss and anemia, but the priority is to ensure the woman’s and fetus’s immediate safety due to placenta previa.

C. Have the client transported to the hospital. This is the correct action. Placenta previa can cause significant bleeding and requires immediate medical attention, including potential delivery. Transporting the client to the hospital ensures she receives the necessary urgent care.

D. Schedule weekly perinatal appointments. Weekly perinatal appointments are important for ongoing care, but in the context of active bleeding and placenta previa, immediate hospital care is necessary first.

A. Ensure that the room is warm and undress the child completely. B. Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary. C. Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia. D. Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing.

Correct Answer is B

Explanation

A: Ensure that the room is warm and undress the child completely. While a warm room is important to keep the child comfortable, undressing the child completely can cause distress and discomfort, especially in toddlers who may feel exposed and vulnerable.

B: Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary. This approach is more appropriate as it allows the child to remain relatively comfortable and secure. The parent’s involvement helps reassure the child, and only removing necessary clothing minimizes distress. It also allows for targeted examination without fully undressing the child, which is less intimidating for toddlers.

C: Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia. Assisting the child in removing clothes can be helpful, but it might be more comforting and less invasive if the parent is involved in this process. Removing underwear only when necessary for a genital examination is appropriate, but it might still be distressing for the child without prior explanation and parental presence.

D: Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing. Demonstrating the process using a paper doll can be an effective way to prepare the child for what will happen during the assessment, reducing anxiety. However, this is more of a preparatory step rather than a direct protocol for the physical assessment itself. It can be a helpful adjunct to the primary method but is not sufficient on its own.

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To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

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