Nokea
The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani’s “click.”
- B. Limited abduction.
- C. Galeazzi’s sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani “click” occurs when the nurse feels the femur sliding into the acetabulum with a “click.” Limited abduction may be observed during an attempt to abduct the infant’s thighs. Galeazzi’s sign reveals femoral foreshortening and is observed by fl exing the thighs.
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When caring for an infant post-repair of an anorectal malformation, which of the following should the nurse monitor to prevent complications?
- A. Skin integrity around the surgical site.
- B. Frequency of oral feedings.
- C. Daily weight gain.
- D. Parental bonding behaviors.
Correct Answer: A
Rationale: Monitoring skin integrity prevents infection and breakdown at the surgical site.
The nurse is caring for a 5-year-old boy who is taking prednisolone for nephrotic syndrome. The child is at the 75th percentile for height and has a blood pressure of 114/73. The nurse compares the reading to the below blood pressure levels for boys age and height percentiles. The nurse determines that the blood pressure represents a change and notifies the primary care provider of the assessment of:
- A. Hypotension.
- B. Prehypertension.
- C. Hypertension.
- D. Hypertension stage II.
Correct Answer: C
Rationale: BP indicates hypertension.
An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother?
- A. The infant will experience a change in the normal home routine.
- B. The infant can return to the prehospital routine immediately.
- C. The infant needs to ingest more calories at home than normal.
- D. The infant will continue to experience abdominal cramping for a few days.
Correct Answer: B
Rationale: After successful surgery, the infant can typically resume normal routines unless complications arise.
The nurse notes that an infant stares at an object placed in her hand and takes it to her mouth, coos and gurgles when talked to, and sustains part of her own weight when held in a standing position. The nurse correctly interprets these findings as characteristic of an infant at which of the following ages?
- A. 2 months.
- B. 4 months.
- C. 7 months.
- D. 9 months.
Correct Answer: B
Rationale: These milestones (visual tracking, mouthing objects, cooing, and partial weight-bearing) are typical at 4 months.
When assessing for pain in a toddler, which of the following methods should be the most appropriate?
- A. Ask the child about the pain.
- B. Observe the child for restlessness.
- C. Use a numeric pain scale.
- D. Assess for changes in vital signs.
Correct Answer: B
Rationale: Toddlers cannot reliably verbalize pain, so observing behavior like restlessness is most appropriate.