A 6-year-old child with autism spectrum disorder (ASD) is hospitalized for a respiratory infection.
The nurse notices the child flapping his hands and rocking in the corner during assessment. What is the best nursing action?

Choice A rationale

Duchenne muscular dystrophy (DMD) is a progressive genetic disorder characterized by muscle degeneration and weakness. Individuals with DMD experience significant muscle weakness, particularly in the lower limbs, leading to an increased risk of falls due to impaired balance and gait instability. Decreased muscle strength directly compromises postural control.

Choice B rationale

Rapid cognitive development is not a typical characteristic of Duchenne muscular dystrophy. While DMD primarily affects skeletal muscles, some individuals may experience cognitive impairments, ranging from mild learning difficulties to more significant intellectual disabilities. The disease is linked to dystrophin deficiency in brain tissue, which can impact neurological function.

Choice C rationale

Increased muscle strength is antithetical to the pathology of Duchenne muscular dystrophy. The hallmark of DMD is progressive muscle weakness caused by the absence or malfunction of dystrophin, a protein vital for maintaining muscle fiber integrity. This leads to chronic muscle damage, inflammation, and eventual replacement of muscle tissue with fat and fibrous tissue.

Choice D rationale

Wheelchair dependence is a common and almost inevitable outcome for individuals with Duchenne muscular dystrophy. Due to the progressive muscle weakness affecting ambulation, most individuals with DMD lose the ability to walk independently between ages 7 and 13, necessitating the use of a wheelchair for mobility as the disease progresses and leg muscles deteriorate.

Choice A rationale

At 16 weeks of gestation, the uterine fundus has not yet reached the umbilicus. The umbilicus is typically reached around 20 weeks of gestation. Palpating the fundus at the umbilicus at 16 weeks would suggest a discrepancy in gestational age or a potential complication such as polyhydramnios or multiple gestation, warranting further investigation.

Choice B rationale

The uterine fundus is palpable at 16 weeks of gestation. By this stage, the uterus has grown significantly and ascended out of the pelvis, making it accessible to abdominal palpation. Failure to palpate the fundus at this stage could indicate an inaccurate gestational age, ectopic pregnancy, or other uterine abnormalities, requiring clinical correlation.

Choice C rationale

At 16 weeks of gestation, the uterine fundus is typically palpable approximately halfway between the symphysis pubis and the umbilicus. This anatomical landmark serves as a reliable indicator of gestational age during the second trimester. The fundus ascends by approximately 1 cm per week after 12 weeks of gestation, providing a consistent growth pattern.

Choice D rationale

At 16 weeks of gestation, the uterine fundus is well above the pubic bone. It typically becomes palpable just above the pubic bone around 12 to 14 weeks of gestation as it rises out of the pelvic cavity. Finding the fundus only just above the pubic bone at 16 weeks would suggest a lag in uterine growth or an inaccurate gestational age assessment.