When changing a diaper on a 2-day-old infant, the practical nurse (PN) observes that the baby's legs are ﬂexed with limited abduction. Based on this finding, what action should the PN take next?

Perform range of motion to the joint.

Continue care since this is a normal finding.

Notify the healthcare provider.

Document the finding in the record.

Answer and Explanation

The Correct Answer is C

Limited abduction of the legs in a newborn can be a sign of developmental dysplasia of the hip (DDH), a condition in which the hip joint is not properly formed. The practical nurse (PN) should notify the healthcare provider of this finding so that further assessment and appropriate intervention can be initiated.

Performing range of motion to the joint (A) is not appropriate without a healthcare provider's order. Continuing care as if this is a normal finding (B) is not appropriate because limited abduction of the legs in a newborn can be a sign of DDH. While documenting the finding in the record (D) is important, notifying the healthcare provider is the most important action for the PN to take next.

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Correct Answer is D

Explanation

Fetal heart rate (FHR) is one of the essential indicators of fetal well-being during labor. A fall in FHR following each contraction is known as recurrent deceleration and can be an indication of fetal distress. In this case, the PN should first reposition the client laterally, as this may help to alleviate compression of the umbilical cord and improve fetal oxygenation.
A. Administering oxygen at 10 L/face mask may be necessary, but it is not the first intervention to be implemented in this scenario.
B. Discontinuing oxytocin infusion may be necessary, but it is not the first intervention to be implemented in this scenario.
C. Observing perineum for cord prolapse is not necessary in this scenario.

A. Increase the intravenous infusion rate. B. Massage the fundus. C. Notify the healthcare provider. D. Assess the vital signs.

Correct Answer is D

Explanation

The most important action for the PN to implement is to **assess the vital signs**. Saturation of a peripad within 15 minutes to 1 hour after delivery must be promptly reported. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage¹. Early recognition and treatment of PPH are critical to care management.

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When changing a diaper on a 2-day-old infant, the practical nurse (PN) observes that the baby's legs are ﬂexed with limited abduction. Based on this finding, what action should the PN take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction. Which intervention should the PN implement first?

Correct Answer is D

Explanation

The practical nurse (PN) is caring for a postpartum client who delivered 5 hours ago and has saturated a perineal pad with a few clots within 15 minutes. Which action is most important for the PN to implement?

Correct Answer is D

Explanation

A normal newborn is admited to the nursery and receives an injection of Phytonadione. The father is watching the nurse administer the injection and asks the practical nurse (PN), "Will my baby get another injection before we can go home?" Which response is best for the PN to provide?

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The practical nurse (PN) is assisting with collecting health information at a health fair for high school students. Which information is most important for the PN to obtain?