A 2-week-old infant is seen in the well-baby clinic. As a nurse is assessing the client, which finding would present as a sign of congenital hip dysplasia?
Examining for the presence of any flexion of the hips when the infant is lying on the abdomen.
Extension of the legs while stimulating the infant to exhibit the stepping reflex.
Negative Babinski reflexes of both feet.
Asymmetrical gluteal folds and unequal leg length.
The Correct Answer is D
Choice A rationale:
Examining for the presence of any flexion of the hips when the infant is lying on the abdomen is a method to assess for Ortolani and Barlow signs, which indicate hip dislocation, not hip dysplasia.
Choice B rationale:
Extension of the legs while stimulating the stepping reflex is a normal developmental response and is not specific to hip dysplasia.
Choice C rationale:
The Babinski reflex is related to neurological development and not directly linked to hip dysplasia.
Choice D rationale:
Asymmetrical gluteal folds and unequal leg length are common findings in congenital hip dysplasia. Hip dysplasia involves improper formation of the hip joint, leading to instability and deformity of the hip socket, which can result in these physical characteristics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Pedal edema is not indicative of digoxin toxicity. Digoxin toxicity primarily affects the heart's electrical activity and rhythm, not fluid accumulation in the extremities.
Choice B rationale:
Cardiac arrhythmias are a hallmark sign of digoxin toxicity. Digoxin can lead to various types of arrhythmias, such as atrial tachycardia, atrial fibrillation, and ventricular ectopy. This occurs due to the drug's effects on altering the electrical conduction in the heart.
Choice C rationale:
Circumoral cyanosis is not a typical sign of digoxin toxicity. This symptom might be seen in conditions like methemoglobinemia or respiratory distress, but it's not directly related to digoxin toxicity.
Choice D rationale:
Infrequent voiding is not a specific sign of digoxin toxicity. It could be related to various factors, such as fluid intake, renal function, or underlying medical conditions, but it's not a hallmark of digoxin toxicity.
Correct Answer is C
Explanation
Choice A rationale:
Preventing contractures of the hips and knees is not directly related to the care of a pediatric patient with congestive heart failure (CHF). CHF primarily involves impaired cardiac function and fluid retention, not joint contractures.
Choice B rationale:
Minimizing cardiac output would be counterproductive in the care of a patient with CHF. The goal is to optimize cardiac output to meet the body's demands while managing the symptoms of CHF.
Choice C rationale:
Minimizing energy expenditure is a major goal in the care of a pediatric patient with CHF. CHF places an extra workload on the heart, and conserving energy helps prevent additional strain on the heart, allowing it to function more efficiently.
Choice D rationale:
Preventing vomiting is not a specific goal related to the care of a pediatric patient with CHF. Vomiting might be a symptom of CHF, but the primary focus is on managing cardiac function and fluid balance.
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