A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?
Neck is in a flexed position
Asymmetry of gluteal folds
Feet turn inward
Frenulum connected to the tip of the tongue
The Correct Answer is A
A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.
B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.
C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.
D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Documenting in the nursing care plan is incorrect. The nursing care plan outlines interventions and client needs, but it is not used for documenting medication errors.
B. Recording in the controlled substance inventory record is incorrect. While the administration of a controlled substance must be recorded, the inventory record tracks medication usage and does not serve as documentation for errors.
C. Completing an incident report is correct. An incident report is used to document medication errors, allowing for review and quality improvement measures to prevent future occurrences.
D. Writing in the provider's progress notes is incorrect. The provider's progress notes focus on client status and treatment plans, not internal error reporting. However, the nurse should notify the provider about the error.
Correct Answer is D
Explanation
A. "Soak in a bathtub of hot water." – Soaking in hot water is not recommended during pregnancy, as it can cause overheating and affect blood flow, potentially leading to complications such as fainting or preterm labor.
B. "Obtain a prescription for pramipexole." – Pramipexole is a medication primarily used for Parkinson’s disease and restless legs syndrome, and it is not typically prescribed to address sleep disturbances during pregnancy.
C. "Use a transcutaneous electrical nerve stimulator (TENS)." – TENS is not generally recommended for treating sleep disturbances during pregnancy. It is more commonly used for pain management.
D. "Lie on your left side with your top leg forward." – Lying on the left side with the top leg forward is a recommended sleeping position during pregnancy, as it can improve blood circulation to the fetus and reduce pressure on the vena cava, which can help improve sleep and comfort
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