A nurse is assessing a I-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?
Femoral head remains in the acetabulum during the Barlow maneuver
Symmetric gluteal and thigh skin folds
Equal leg length
Limited hip abduction
The Correct Answer is D
Rationale:
A. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding, indicating that the hip joint is stable and not dislocated.
B. Symmetric gluteal and thigh skin folds: Symmetry suggests normal hip alignment and absence of hip dysplasia.
C. Equal leg length: Equal leg length is expected and indicates no hip dislocation.
D. Limited hip abduction: Limited abduction in a 1-month-old may indicate developmental dysplasia of the hip (DDH). In DDH, the femoral head does not fully seat in the acetabulum, restricting outward movement. Early diagnosis prevents long-term complications such as gait abnormalities or limb-length discrepancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Varicella (chickenpox) requires airborne and contact precautions, not droplet precautions, due to its high transmissibility.
B. Aspirin should never be given to children with viral infections because it increases the risk of Reye’s syndrome, a life-threatening condition causing liver failure and encephalopathy.
C. The herpes zoster vaccine (Zostavax or Shingrix) is for adults to prevent shingles, not for children with active varicella infection.
D. Children with varicella are contagious from 1–2 days before the rash appears until all vesicles have crusted over (usually 5–7 days). They should be isolated from susceptible individuals during this period.
Correct Answer is B
Explanation
Rationale:
A. Lifting under the axilla risks musculoskeletal injury to both the nurse and client. This technique violates safe handling guidelines.
B. A powered mechanical lift is required when the client is heavy and unable to assist, as it minimizes nurse injury and ensures safe, smooth movement.
C. A gait belt is used only for clients who can bear partial weight and actively assist in the transfer. This client cannot assist.
D. A sliding board requires some upper body strength and cooperation, which this client lacks. Therefore, it is unsafe for this situation.
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