An infant has just returned from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous,but there is color, sensitivity,and movement to them. The nurse should
1. call the physician to report theedema.
2. elevate the legs on pillows.
3. apply a warm moist pack to the feet.
4. encourage movement of toes.
Answer:2
Rationale: The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return.Some amount of swelling can be expected, so it would not be appropriate to notify the physician,especially if the color, sensitivity,and movement remained normal to the toes.Ice should be applied,not heat. An infant would not be able to follow directions to move toes,and in this case it would not be as effective as elevating the legs on pillows.
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