The nurse is assisting the health care provider (HCP) in examining an infant with suspected congenital hip dysplasia.
What sign should the nurse expect to find during the assessment?
Clear fluid oozing out of the pilonidal sinus.
Positive hip click bilaterally.
Erythema toxicum on the torso.
Limited abduction of the affected hip.
The Correct Answer is D
Choice A rationale
Clear fluid oozing from a pilonidal sinus is unrelated to congenital hip dysplasia and more associated with other conditions like pilonidal cysts.
Choice B rationale
A positive hip click can indicate hip instability but is not definitive for congenital hip dysplasia.
Choice C rationale
Erythema toxicum is a benign, self-limiting skin condition and does not relate to hip dysplasia.
Choice D rationale
Limited abduction of the hip is a key sign of congenital hip dysplasia, indicating restricted movement due to abnormal hip joint development. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice B rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice C rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice D rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.
Choice B rationale
Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.
Choice C rationale
A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.
Choice D rationale
A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.
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