A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
Inwardly turned foot on the affected side
Absent plantar reflexes
Lengthened thigh on the affected side
Asymmetric thigh folds
The Correct Answer is D
Choice A reason:
Inwardly turned foot on the affected side: An inwardly turned foot, also known as metatarsus adductus, is not typically associated with developmental dysplasia of the hip (DDH). This condition is more related to foot positioning and alignment rather than hip dysplasia.
Choice B reason:
Absent plantar reflexes: The plantar reflex, also known as the Babinski reflex, is usually present in newborns and indicates normal neurological function. An absent plantar reflex is not a common finding in DDH and would more likely suggest a neurological issue.
Choice C reason:
Lengthened thigh on the affected side: In DDH, the affected thigh is often shorter, not longer, due to the displacement of the femoral head from the acetabulum. This can lead to a noticeable difference in leg length.
Choice D reason:
Asymmetric thigh folds: Asymmetric thigh folds are a common sign of DDH. When the hip is dislocated or subluxated, it can cause uneven skin folds on the thighs and buttocks. This asymmetry is a key indicator that prompts further investigation, such as an ultrasound or X-ray.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is b) “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”
Choice A reason:
The statement “There is no need to worry about that. Most forms of hearing loss are not inherited” is not entirely accurate. While it is true that not all forms of hearing loss are inherited, genetic factors can play a significant role in hearing loss. Approximately 50-60% of hearing loss in infants is due to genetic causes. Therefore, dismissing the concern without proper screening is not advisable.
Choice B reason:
Routine hearing screenings are conducted on newborns to detect any hearing issues early. These screenings are typically performed before the baby leaves the hospital. The two main types of newborn hearing screenings are Otoacoustic Emissions (OAEs) and Automated Auditory Brainstem Response (AABR). These tests are safe, painless, and can identify hearing loss early, allowing for timely intervention. Early detection is crucial for the development of speech, language, and social skills.
Choice C reason:
Clapping hands loudly to see if the baby startles is not a reliable method to determine hearing ability. While a startle response might indicate that the baby can hear, it does not provide comprehensive information about the baby’s hearing capabilities. Newborn hearing screenings are more accurate and can detect even mild hearing loss.
Choice D reason:
Observing how the baby looks at you when you speak is also not a reliable method to assess hearing. Babies can respond to visual cues and vibrations, which might give the impression that they can hear. However, this method does not provide a definitive assessment of the baby’s hearing ability. Professional hearing screenings are necessary to accurately determine hearing status.
Correct Answer is B
Explanation
Choice A Reason:
While assessing bowel sounds is important for overall patient care, it is not the priority when administering magnesium sulfate. Magnesium sulfate is primarily used to prevent seizures in preeclampsia and to manage preterm labor. Its side effects can include respiratory depression, making respiratory rate the most critical assessment.
Choice B Reason:
Respiratory rate is the priority assessment when administering magnesium sulfate. Magnesium sulfate can cause respiratory depression, which can be life-threatening. Monitoring the respiratory rate helps ensure that the client is not experiencing adverse effects from the medication. The normal respiratory rate for adults is 12-20 breaths per minute.
Choice C Reason:
Temperature monitoring is important for detecting infections and other conditions, but it is not the priority in this context. Magnesium sulfate does not typically affect body temperature, so this assessment is less critical compared to respiratory rate.
Choice D Reason:
Fetal heart rate (FHR) monitoring is crucial for assessing fetal well-being, especially in clients with preeclampsia or preterm labor. However, the immediate priority when administering magnesium sulfate is to monitor the mother’s respiratory rate to prevent respiratory depression.
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