An infant returns to the unit following casting of the leg for ...

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An infant returns to the unit following casting of the leg for talipes equinovarus. Standing orders include monitoring the neurovascular status.
 
  In addition to color, for what will the nurse monitor the infant's foot? Standard Text: Select all that apply. 1. Warmth
  2. Capillary refill
  3. Pedal pulse
  4. Sensation
  5. Movement of the toes

Question 2

An 18-month-old child is admitted to the hospital unit for weakness of the lower extremities. Duchenne muscular dystrophy is suspected. Which assessment finding on the admission history and physical is indicative of this disorder?
 
  1. Infant was post-mature by almost two weeks.
  2. The child seems very muscular.
  3. The child walked early and without support at 10 months.
  4. The child's older sister developed scoliosis in the fourth grade.

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Answer to Question 1

1,2,4,5
Rationale 1: The temperature of the foot of the casted leg should be compared to the temperature of the other foot.
Rationale 2: This indicates blood return to the tissues and is an important finding.
Rationale 3: The pedal pulse cannot be reached in the casted foot.
Rationale 4: Nerve function is evaluated by touching the toes and noting the child's response.
Rationale 5: The child is encouraged to wiggle the toes. If the patient is an infant, tickling will cause the child to respond with movement.
Global Rationale:

Answer to Question 2

2
Rationale 1: Post-maturity is not related to Duchenne muscular dystrophy.
Rationale 2: Duchenne muscular dystrophy is also called pseudohypertrophic due to the enlarged appearance of the muscle. The pathophysiology is infiltration of the muscle fibers with fatty tissue.
Rationale 3: This finding is not indicative of Duchenne muscular dystrophy.
Rationale 4: The older sister's scoliosis is not related to MD. Duchenne MD is sex-linked recessive and affects only boys.
Global Rationale: