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 D
Explanation
A) Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B) Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C) Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D) Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.
Correct Answer is A
Explanation
Following a pneumonectomy, it is important for the client to gradually resume normal activities and engage in social interactions. Encouraging family gatherings can provide emotional support, facilitate social connections, and help reduce feelings of isolation that the client may be experiencing.
While it is generally important for clients who have undergone a pneumonectomy to take precautions to reduce the risk of respiratory infections, such as avoiding crowded places and individuals with respiratory infections, completely avoiding social contact for several weeks is not necessary or realistic in most cases. It is essential to find a balance between protecting the client's health and promoting their emotional well-being and social integration.
Wearing a face mask during family events may not be necessary unless there is a specific concern about respiratory infections. The nurse can educate the client about the importance of good hand hygiene and avoiding close contact with individuals who are actively ill with respiratory infections.
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