The nurse suspects clubfoot in the newborn and assesses for the condition by:
1. Adducting the foot and listening for a click.
2. Moving the foot to midline and determining resistance.
3. Extending the foot and observing for pain.
4. Stimulating the sole of the foot.
2
Rationale 1: Adducting the foot and listening for a click is not a typical assessment.
Rationale 2: Clubfoot is suspected when the foot does not turn to a midline position or align readily.
Rationale 3: Extending the foot and observing for pain does not confirm or rule out clubfoot.
Rationale 4: Stimulating the sole of the foot elicits the plantar grasp reflex, and is not an appropriate assessment for clubfoot.
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