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 C
Explanation
The client with Addison's disease is experiencing weakness, confusion, and dehydration, which can be indicative of an adrenal crisis. The low sodium level (129 mEq/L) and low glucose level (54 mg/dl) further support this suspicion. An acute viral infection can trigger an adrenal crisis in individuals with Addison's disease.
Intravenous hydrocortisone, a glucocorticoid, is the treatment of choice for managing an adrenal crisis. It helps to replenish cortisol levels and stabilize the client's condition.
Hydrocortisone helps in restoring the body's stress response and regulating electrolyte and glucose levels.
A broad-spectrum antibiotic may be necessary if there is evidence of a bacterial infection, but it does not directly address the symptoms associated with Addison's disease.
Regular insulin is used for managing high blood glucose levels in conditions such as diabetes, but in this case, the client has low glucose levels, so insulin is not the appropriate intervention.
Potassium chloride is a medication used to treat low potassium levels (hypokalemia), but the client's potassium level is within the reference range (5.3 mEq/L). Therefore, potassium chloride is not indicated in this situation.
Correct Answer is C
Explanation
A) Incorrect- Furosemide is a loop diuretic used to treat conditions such as edema and hypertension. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
B) Incorrect- Low-dose aspirin is often used for its antiplatelet effects to prevent cardiovascular events. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
C) Correct- Allopurinol is a medication used to treat gout by reducing the production of uric acid in the body. However, allopurinol can also increase the risk of forming calcium oxalate kidney stones, which is the type of kidney stone mentioned in the client's history. Calcium oxalate stones are the most common type of kidney stone, and they are composed primarily of calcium and oxalate. In this case, the client has a history of gout and is prescribed allopurinol. The nurse should bring the client's prescription for allopurinol to the healthcare provider's attention because
it has the potential to contribute to the formation of kidney stones, which could exacerbate the client's existing condition.
D) Incorrect- Enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
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