A nurse is assessing a newborn and evaluating for developmental dysplasia of the hip (DDH). What assessment finding would indicate DDH?
Inwardly turned foot on the affected side.
Gluteal folds are asymmetrical.
Absence of Babinski sign.
Absence of stepping reflex.
The Correct Answer is B
Choice A rationale
An inwardly turned foot is not a sign of DDH. It may indicate a different condition such as clubfoot.
Choice B rationale
Asymmetrical gluteal folds are a common sign of developmental dysplasia of the hip (DDH). This occurs because the hip joint is not properly aligned, causing uneven skin folds.
Choice C rationale
The absence of the Babinski sign is not related to DDH. The Babinski sign is a reflex test used to assess neurological function.
Choice D rationale
The absence of the stepping reflex is not related to DDH. The stepping reflex is a normal newborn reflex that disappears after a few months.
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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate.
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide.
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level.
Correct Answer is C
Explanation
Choice A rationale
Wiping the cord daily with alcohol prep pads is not recommended. Current guidelines suggest keeping the cord clean and dry without the use of alcohol, as it can delay the natural drying and falling off process.
Choice B rationale
Keeping the cord moist is not recommended. The cord should be kept dry to promote natural drying and separation. Moisture can increase the risk of infection.
Choice C rationale
Folding the top of the diaper underneath the cord is recommended to keep the cord exposed to air and prevent irritation from urine or stool. This helps the cord dry out and fall off naturally.
Choice D rationale
Applying petroleum jelly to the cord stump is not recommended. The cord should be kept dry, and the use of ointments or creams can interfere with the natural drying process. .