ATI RN
ATINur2708 Pediatrics Final Exam Questions
Extract:
3-week-old child with bilateral clubfoot, increasingly irritable, bilateral leg casts, pallor and coolness of left foot.
Question 1 of 5
The home care nurse is assessing a 3 week old child with history of bilateral clubfoot noted at birth. The mother reports that the infant has been increasingly irritable in the last day. Assessment findings include: bilateral leg casts in place, child is irritable; pallor and coolness of left foot is noted. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C: Refer child for immediate intervention in Emergency Department. The priority action is to address the pallor and coolness of the left foot, which may indicate compromised circulation. This could be a sign of vascular compromise, such as compartment syndrome, which is a medical emergency requiring urgent intervention to prevent tissue damage. Assessing for skin breakdown (choice
B) and providing cast care (choice
D) are important but secondary to addressing the potential vascular issue. Range of motion exercises (choice
A) are not appropriate in this situation and may exacerbate the problem.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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