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 B

Explanation

Rationale:

A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler's position is commonly used postoperatively to promote lung expansion, prevent aspiration, and support comfort. This is an appropriate nursing action that does not require correction.

B. The nurse performs auscultation of the lungs without lifting the gown: Lung auscultation should always be performed on bare skin to ensure accurate assessment of breath sounds. Clothing can muffle or distort the sounds, potentially leading to misinterpretation or missed abnormalities.

C. The nurse applies a cold compress to reduce localized swelling: Cold therapy is appropriate for managing inflammation, bruising, or swelling in many clinical settings. This demonstrates correct therapeutic intervention and does not indicate a need for further instruction.

D. The nurse uses clean gloves when administering an enema: Clean (non-sterile) gloves are appropriate for enema administration since it is a non-sterile procedure. This action follows standard precautions and is acceptable for routine nursing care.

A. The client advances the walker and takes a step towards it. B. The client grasps the walker by the hand grips on the upper bars. C. The client lifts the walker as it is moved forward. D. The client takes multiple steps while holding the walker.

Correct Answer is D

Explanation

Rationale:

A. The client advances the walker and takes a step towards it: This is the correct technique for using a walker. The client should move the walker a short distance ahead, then step into it one foot at a time, maintaining balance and stability throughout the motion.

B. The client grasps the walker by the hand grips on the upper bars: Holding the walker by its designated hand grips is safe and appropriate. This ensures proper control of the device and minimizes the risk of slipping or tipping.

C. The client lifts the walker as it is moved forward: Walkers should be lifted and placed rather than dragged to maintain balance and prevent tripping. This action demonstrates proper use and helps maintain floor contact with all legs of the walker.

D. The client takes multiple steps while holding the walker: Taking multiple steps without first advancing the walker compromises balance and increases the risk of falling. The correct method involves moving the walker first, then taking one step at a time toward it.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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