A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Limited hip abduction

Equal leg length

Symmetric gluteal and thigh skin folds

Femoral head remains in the acetabulum during the Barlow maneuver

Answer and Explanation

The Correct Answer is A

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

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Correct Answer is A

Explanation

Rationale:

A. Assist the adolescent in applying for Medicaid: Medicaid can provide essential prenatal care, delivery services, and pediatric coverage for low-income individuals. Helping the adolescent apply addresses both her financial and health concerns, supporting positive outcomes.

B. Refer the adolescent to local mental health clinic: While emotional support is important, this action doesn’t directly address her stated concern about affording and caring for the baby. It may be appropriate later but is not the immediate priority.

C. Contact the adolescent parent for assistance: Contacting family may be helpful if the adolescent consents, but it must respect her autonomy and confidentiality. It is not the nurse’s first step without permission or expressed need for family involvement.

D. Advise the adolescent to place the newborn for adoption: Suggesting adoption without the adolescent initiating that discussion may be inappropriate and coercive. Nurses should provide options neutrally and supportively, not direct decisions about parenting or adoption.

A. A small area rug is placed at the front door. B. The water heater is set at 54° C (129.2° F). C. The batteries in the smoke alarms are changed annually. D. A single light fixture hangs along the sidewalk to the house.

Correct Answer is C

Explanation

Rationale:

A. A small area rug is placed at the front door: Area rugs increase the risk of falls, especially in older adults or clients with mobility issues. Rugs should be removed or secured with non-slip backing to prevent tripping hazards at entrances and high-traffic areas.

B. The water heater is set at 54° C (129.2° F): This temperature is too high and poses a significant risk for burns or scalding. The recommended maximum water heater setting for safety is 49° C (120° F), especially in homes with children or older adults.

C. The batteries in the smoke alarms are changed annually: Changing smoke alarm batteries once a year aligns with fire safety recommendations. Functioning smoke alarms are a critical part of home safety and fire prevention.

D. A single light fixture hangs along the sidewalk to the house: One light may not provide adequate visibility, especially in poor weather or at night. Multiple, evenly spaced light sources are more effective for preventing trips or falls along walkways.

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A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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