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A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

A.

Xiphoid process.

B.

Fifth intercostal space.

C.

Sternal notch.

D.

Nipple line.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

The xiphoid process is not the correct anatomical landmark for measuring chest circumference in newborns. It is located at the lower end of the sternum and does not provide a consistent measurement point.

 

Choice B rationale

 

The fifth intercostal space is not used for measuring chest circumference in newborns. This space is located between the ribs and is not a reliable landmark for consistent measurements.

 

Choice C rationale

 

The sternal notch is not the correct landmark for measuring chest circumference. It is located at the top of the sternum and does not provide a consistent measurement point.

 

Choice D rationale

 

The nipple line is the correct anatomical landmark for measuring chest circumference in newborns. This method ensures that the measurement is taken at a consistent and reproducible location, providing an accurate assessment of the chest size relative to growth and development standards.

 


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View Related questions

Correct Answer is B

Explanation

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.

Correct Answer is A

Explanation

Choice A rationale

The Babinski reflex is elicited by stroking the outer edge of the sole of the newborn’s foot, moving up toward the toes. This causes the big toe to move upward and the other toes to fan out.

Choice B rationale

Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, not the Babinski reflex.

Choice C rationale

Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex, not the Babinski reflex.

Choice D rationale

Clapping near the crib and making a loud noise is used to elicit the startle (Moro) reflex, not the Babinski reflex.

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