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 A
Explanation
A) Correct- Zidovudine is an antiretroviral medication used in the treatment of HIV infection.
One of the potential side effects of zidovudine is hematological toxicity, including anemia (low red blood cell count) and neutropenia (low white blood cell count). The appearance of pinpoint, red, round spots on the skin could be indicative of petechiae, which are small hemorrhages caused by the leakage of blood into the skin. Petechiae can occur due to low platelet counts, a
component of the complete blood count (CBC). Monitoring the complete blood count is important for clients receiving zidovudine to identify any potential adverse effects on blood cell counts. Anemia and neutropenia can increase the risk of infection, bleeding, and other complications. Therefore, any changes in blood cell counts, including the presence of petechiae, should be reported to the healthcare provider for further evaluation and management.
B) Incorrect- This is used to assess allergic reactions and is not specifically related to the appearance of petechiae.
C) Incorrect- A skin biopsy is typically performed to diagnose skin conditions or diseases and is not the primary assessment to evaluate the cause of petechiae.
D) Incorrect- Electromyography is a diagnostic test used to assess muscle and nerve function and is not relevant to the appearance of petechiae associated with zidovudine use.
Correct Answer is D
Explanation
Choice A rationale: White blood cell count monitors for infection or inflammation. While important for general health, it does not address the massive fluid loss and electrolyte imbalances specifically caused by diabetes insipidus.
Choice B rationale: Capillary glucose monitors for diabetes mellitus. Diabetes insipidus involves antidiuretic hormone deficiency, not insulin issues; therefore, glucose levels are not the priority in managing the massive dilute polyuria seen here.
Choice C rationale: Urine specific gravity will be consistently low in diabetes insipidus. While it confirms the diagnosis of dilute urine, it is less critical than monitoring the life-threatening systemic effects of dehydration.
Choice D rationale: Serum sodium is the most important lab to monitor. Massive loss of dilute urine leads to severe hemoconcentration and hypernatremia, which can cause cerebral edema, seizures, and permanent neurological damage.
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