A nurse is assessing a I-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?
Femoral head remains in the acetabulum during the Barlow maneuver
Symmetric gluteal and thigh skin folds
Equal leg length
Limited hip abduction
The Correct Answer is D
Rationale:
A. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding, indicating that the hip joint is stable and not dislocated.
B. Symmetric gluteal and thigh skin folds: Symmetry suggests normal hip alignment and absence of hip dysplasia.
C. Equal leg length: Equal leg length is expected and indicates no hip dislocation.
D. Limited hip abduction: Limited abduction in a 1-month-old may indicate developmental dysplasia of the hip (DDH). In DDH, the femoral head does not fully seat in the acetabulum, restricting outward movement. Early diagnosis prevents long-term complications such as gait abnormalities or limb-length discrepancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. “Client in room 302 has had high blood glucose levels.” This statement lacks specific data (values, trends, or interventions) and is too vague to be useful.
B. “Client in room 304 is here because they are seeking narcotics.” This is a judgmental and non-objective statement, violating professional communication standards.
C. "Client in room 303 takes too many medications for their condition." This is subjective and unprofessional; only factual data should be reported.
D. “Client in room 301 is in the cardiac catheterization laboratory.” Objective, relevant information about the client’s current location, procedures, and treatments should be included in a shift report to ensure continuity of care.
Correct Answer is B
Explanation
A. This reflects acceptance and adaptation, not body image disturbance.
B. Avoiding mirrors or lights when undressing indicates embarrassment, shame, or distress about appearance, which are classic signs of disturbed body image.
C. Willingness to join a support group suggests positive coping and readiness for adjustment.
D. Expressing interest in reconstructive surgery shows hope and proactive adaptation, not negative body image.
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