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
Which of the following should the nurse do first? 1. Call the physician to report the edema.
2. Elevate the legs on pillows.
3. Apply a warm, moist pack to the feet.
4. Encourage movement of toes.
2
Rationale:
1. 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.
2. The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return.
3. Ice should be applied, not heat.
4. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as would elevating the legs on pillows.
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