The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?
Ortolani maneuver causing a click at the hip joint.
Plumb line test indicates fetal position curvature.
Babinski test that reveals fanning out of toes.
Moro test precipitating a startle response.
The Correct Answer is A
The Ortolani maneuver is a physical examination technique used to assess for developmental dysplasia of the hip (DDH) in newborns. During the maneuver, the nurse gently abducts the infant's hips and applies gentle pressure to detect any instability or "click" at the hip joint. A positive Ortolani maneuver, where a click or clunk is felt or heard, can indicate the presence of a hip dislocation or dysplasia.
Asymmetrical buttocks can be a sign of hip dysplasia in newborns, and a positive Ortolani maneuver is an important finding that suggests a potential hip joint problem. Reporting this assessment test result to the healthcare provider allows for further evaluation and appropriate management of the newborn's hip condition.
The Plumb line test, which assesses fetal position curvature, is not directly related to hip dysplasia and may not be significant in this context.
The Babinski test, which reveals fanning out of the toes, is used to assess the integrity of the infant's neurological system and is not specific to hip dysplasia.
The Moro test, also known as the startle response, is a reflex assessment used to evaluate the newborn's neurological and sensory function. While it is important to assess the overall neurological status of the newborn, the Moro test is not specific to hip dysplasia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
In this scenario, the client is experiencing difficulty falling asleep at night, fatigue, and daytime sleepiness. These symptoms may indicate that the client's exercise routine is impacting their sleep patterns. By asking the client for a description of their exercise schedule, the nurse can gather important information about the timing, intensity, and duration of the client's exercise regimen.
Exercise has numerous benefits for sleep and overall health, but the timing and intensity of exercise can affect sleep patterns differently for individuals. Vigorous exercise close to bedtime may increase alertness and make it harder for some people to fall asleep.
Therefore, understanding the client's exercise routine will help the nurse assess if the timing or intensity of the exercise is contributing to the sleep issues.
Based on the information gathered, the nurse can provide appropriate guidance. This may include adjusting the timing of exercise to earlier in the day, reducing the intensity of exercise closer to bedtime, or considering other factors that may be contributing to the sleep difficulties, such as caffeine intake, stress, or environmental factors.
Correct Answer is ["A","B","D","E"]
Explanation
Nursing Interventions for Client Starting Clonazepam:
The following nursing interventions are appropriate for the client starting clonazepam 0.25 mg PO every 12 hours:
a. Screen for orthostatic hypotension:
Rationale:
- Clonazepam,like other benzodiazepines,can cause central nervous system (CNS) depression,which can lead to hypotension,particularly orthostatic hypotension.This occurs when blood pressure drops suddenly upon standing due to impaired autonomic nervous system regulation.
- Screening for orthostatic hypotension involves measuring the client's blood pressure and heart rate while lying down and then again after standing for 3 minutes.A significant drop in blood pressure (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg) or increase in heart rate (over 20 beats per minute) indicates orthostatic hypotension.
- Monitoring for orthostatic hypotension is crucial to prevent falls and other complications,especially in older adults or those with pre-existing cardiovascular conditions.
b. Provide oral care at least twice a day:
Rationale:
- Clonazepam can cause dry mouth as a side effect,which can increase the risk of cavities,gum disease,and oral infections.
- Regular oral care helps to remove plaque and bacteria,promoting oral hygiene and preventing complications.Providing oral care at least twice a day,especially before bedtime and upon waking,is essential.
d. Assess mental status regularly:
Rationale:
- Clonazepam,while indicated for anxiety and insomnia,can paradoxically cause agitation,confusion,and even hallucinations in some individuals,particularly older adults or those with pre-existing psychiatric conditions.
- Regular assessment of mental status helps to identify any adverse behavioral or cognitive changes early on.This includes monitoring for anxiety,depression,suicidal ideation,confusion,disorientation,hallucinations,and changes in sleep patterns.
e. Assist the client to the bathroom:
Rationale:
- Clonazepam can cause drowsiness and dizziness,which can increase the risk of falls,especially in older adults or those with impaired mobility.
- Assisting the client to the bathroom and providing support during toileting activities helps to prevent falls and injuries.
Choices not included:
c. Monitor calcium levels:
- There is no specific indication for monitoring calcium levels with clonazepam use.
f. Have an opioid agonist at the bedside:
- Clonazepam is not indicated for pain management and does not interact significantly with opioid analgesics.Therefore,having an opioid agonist readily available is not a necessary intervention for clonazepam initiation.
Additional Considerations:
- Educate the client about the potential side effects of clonazepam,including drowsiness,dizziness,dry mouth,and cognitive changes.
- Advise the client to avoid alcohol and other CNS depressants while taking clonazepam,as this can increase the risk of sedation and respiratory depression.
- Instruct the client to take clonazepam exactly as prescribed and not to stop taking it abruptly,as this can lead to withdrawal symptoms.
- Monitor the client's sleep patterns and adjust the medication schedule if necessary.
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