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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The practical nurse (PN) should recognize that a newborn whose mother has poorly controlled type 1 diabetes mellitus and is exhibiting grunting with mild sternal retractions is exhibiting signs of patent ductus arteriosus. Patent ductus arteriosus is a condition in which the ductus arteriosus, a blood vessel that connects the pulmonary artery to the aorta, fails to close after birth. This can result in abnormal blood flow between the aorta and pulmonary artery, leading to respiratory distress.
Hypothyroidism (Option A) and hyperinsulinemia (Option C) are conditions that can occur in newborns, but they do not typically present with grunting and sternal retractions.
Ventral septal defect (Option D) is a congenital heart defect that can cause respiratory distress, but it is not specifically associated with maternal diabetes.
Correct Answer is B
Explanation
The PN should report the injury details to the charge nurse. This is important because the charge nurse needs to be aware of any changes in the patient's condition and can help determine the appropriate course of action. The other options are not the most appropriate actions for the PN to take in this situation.
Obtaining a heel stick glucose (A) may be necessary if hypoglycemia is suspected, but it is not the most immediate concern.
Initiating strict intake and output measurements (C) may be necessary for monitoring fluid balance, but it is not the most immediate concern.
Swaddling the infant in a blanket (D) may provide comfort, but it does not address the underlying issue of the head injury and seizure episode.
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