The nurse is caring for an infant with developmental dysplasia of the hip. Which clinical manifestations would the nurse expect to observe? (Select all that apply.)
Positive Ortolani click
Unequal gluteal folds
Trendelenburg sign
Negative Babinski sign
Telescoping of the affected limb
Correct Answer : A,B,C,E
The correct answer is a) Positive Ortolani click, b) Unequal gluteal folds, c) Trendelenburg sign, and e) Telescoping of the affected limb.
Choice A reason:
A positive Ortolani click is a clinical manifestation of developmental dysplasia of the hip (DDH). The Ortolani maneuver is used to detect hip dislocation or subluxation in infants. When the hip is abducted and gentle pressure is applied to the proximal thigh from behind, a palpable “clunk” is noticed as the femoral head relocates into the acetabulum. This indicates hip instability, which is a characteristic of DDH.
Choice B reason:
Unequal gluteal folds are another clinical manifestation of DDH. Asymmetrical gluteal creases can suggest hip dysplasia in infants. This is because the dislocation or subluxation of the hip can cause one leg to appear shorter than the other, leading to uneven gluteal folds.
Choice C reason:
The Trendelenburg sign is a clinical test used to assess the integrity and strength of the hip abductor muscles, particularly the gluteus medius and gluteus minimus. A positive Trendelenburg sign usually indicates weakness in these muscles, which can be associated with hip abnormalities such as congenital hip dislocation3. In DDH, the hip instability can lead to a positive Trendelenburg sign.
Choice D reason:
A negative Babinski sign is not a clinical manifestation of DDH. The Babinski reflex is a normal reflex in infants up to 2 years old, where the big toe moves upward and the other toes fan out when the sole of the foot is stroked. A negative Babinski sign would indicate the absence of this reflex, which is not related to DDH.
Choice E reason:
Telescoping of the affected limb is a clinical manifestation of DDH. In a child with DDH, the hip socket is shallow, and the head of the femur may slip in and out, leading to a telescoping effect. This means the femoral head can move further out of the socket, causing the limb to appear shorter or longer depending on the position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Cleansing the suture line, maintaining an upright position, and using arm restraints are crucial aspects of postoperative care for an infant after cleft lip repair. Cleansing the suture line helps prevent infection and promotes healing. Keeping the infant in an upright position reduces the risk of aspiration and helps with breathing. Arm restraints prevent the infant from touching or rubbing the surgical site, which could disrupt the healing process.
Choice B Reason:
Mouth irrigations and a prone position are not recommended for postoperative care after cleft lip repair. Mouth irrigations can be too harsh for the delicate surgical site, and a prone position (lying face down) can increase the risk of aspiration and breathing difficulties. Cleansing the suture line is important, but the other aspects of this choice are not suitable.
Choice C Reason:
Frequent oral suction and spoon feeding are not appropriate for an infant after cleft lip repair. Oral suction can be too aggressive and may damage the surgical site. Spoon feeding is not recommended as it can put pressure on the healing lip. Giving a teething toy is also not advisable as it can cause the infant to put objects in their mouth, potentially harming the surgical site.
Choice D Reason:
Arm restraints are indeed necessary to prevent the infant from touching the surgical site. However, postural drainage and mouth irrigations are not suitable for postoperative care after cleft lip repair. Postural drainage is not relevant to this condition, and mouth irrigations can be too harsh for the healing tissue.
Correct Answer is D
Explanation
Choice A reason:
Monitor your child’s temperature daily: Monitoring temperature is important for children with sickle cell anemia as they are prone to infections. A fever can be an early sign of infection, which can be serious for these children. Normal body temperature for children ranges from 36.5°C to 38°C. However, while monitoring temperature is important, it is not the most critical daily advice compared to ensuring adequate hydration.
Choice B Reason:
Restrict outdoor play to 1 hour per day: Limiting outdoor play is not typically necessary unless the child is experiencing extreme fatigue or pain. Physical activity is generally encouraged to maintain overall health, but it should be balanced with rest and hydration. Therefore, this advice is not as crucial as ensuring the child stays hydrated.
Choice C Reason:
Apply cold compresses when your child expresses pain: Cold compresses are not recommended for managing pain in sickle cell anemia. Instead, warm compresses or heating pads are often suggested to help relieve pain by improving blood flow. Cold can cause vasoconstriction, which may worsen pain and complications.
Choice D Reason:
Offer your child fluids frequently to meet their daily fluid goals: Staying well-hydrated is essential for children with sickle cell anemia. Adequate hydration helps prevent sickle cell crises by reducing blood viscosity and promoting better blood flow. This is the most appropriate and critical advice for daily care.
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