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 C
Explanation
Choice A rationale:
Tucking small disposable diapers under the cast edges in the buttock area may cause discomfort to the patient and could also potentially disrupt the cast alignment. It may also not effectively prevent soiling.
Choice B rationale:
Lining the edges of the cast with absorbent pads and securing with tape might not fully protect the cast from urine and feces. The absorbent pads could still allow some leakage and contamination.
Choice C rationale:
Placing a large cloth diaper over the perineal cutout area provides comprehensive protection against urine and feces soiling the cast. This method ensures that the cast remains clean and dry.
Choice D rationale:
Laying the client on a disposable pad with the perineal area exposed to air is not a practical solution. It does not offer adequate protection for the cast, and exposing the perineal area to air could lead to discomfort and potential complications.
Correct Answer is C
Explanation
Choice A rationale:
Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.
Choice B rationale:
Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.
Choice C rationale:
Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.
Choice D rationale:
Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.
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