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","B","C","E"]
Explanation
Choice A rationale
Sucking on their fingers is an early hunger cue in infants. It indicates that the baby is ready to feed.
Choice B rationale
Smacking their lips is another early hunger cue. It shows that the baby is thinking about feeding.
Choice C rationale
Extending their tongue is also an early hunger cue. It indicates that the baby is ready to latch onto the breast or bottle.
Choice D rationale
Crying is a late hunger cue. It is better to feed the baby before they start crying to make feeding easier.
Choice E rationale
Rooting is an early hunger cue. It involves the baby turning their head towards the breast or bottle, indicating they are ready to feed. .
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.