When changing a diaper on a 2-day-old infant, the practical nurse (PN) observes that the baby's legs are flexed with limited abduction. Based on this finding, what action should the PN take next?
Perform range of motion to the joint.
Continue care since this is a normal finding.
Notify the healthcare provider.
Document the finding in the record.
The Correct Answer is C
Limited abduction of the legs in a newborn can be a sign of developmental dysplasia of the hip (DDH), a condition in which the hip joint is not properly formed. The practical nurse (PN) should notify the healthcare provider of this finding so that further assessment and appropriate intervention can be initiated.
Performing range of motion to the joint (A) is not appropriate without a healthcare provider's order. Continuing care as if this is a normal finding (B) is not appropriate because limited abduction of the legs in a newborn can be a sign of DDH. While documenting the finding in the record (D) is important, notifying the healthcare provider is the most important action for the PN to take next.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
During pregnancy, it is important for the client to consume a balanced and nutritious diet that includes adequate protein, vitamins, and minerals. However, clients with nausea and vomiting may have difficulty tolerating certain foods, particularly those that are high in fat or spicy. Cheeseburgers and French fries are typically high in fat and can exacerbate nausea, making them a poor choice for a client with this symptom.
Baked chicken with rice and pasta with steamed vegetables are both healthier options that can provide the client with adequate nutrition.
Baked potato chips and lemonade may be a suitable snack for some clients, but the high salt content of the chips may exacerbate fluid retention, which can be a concern for clients with pyelonephritis. The PN should encourage the client to choose healthier options and avoid foods that are likely to exacerbate her symptoms.
Correct Answer is D
Explanation
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
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