Author Question: The nurse in the newborn nursery is performing the admission assessment on a neonate. Which ... (Read 114 times)

kodithompson · **on:** Jun 28, 2018

The nurse in the newborn nursery is performing the admission assessment on a neonate. Which assessment finding indicates the neonate may have congenital hip dysplasia?

1. Asymmetry of the gluteal and thigh fat folds
2. Trendelenburg sign
3. Telescoping of the affected limb
4. Lordosis

Question 2

An infant returns from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them.

Which action by the nurse is the most appropriate?
1. Call the healthcare provider to report the edema.
2. Elevate the legs on pillows.
3. Apply a warm, moist pack to the feet.
4. Encourage movement of toes.

mjbamaung · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

Correct Answer: 1
Rationale: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

Answer to Question 2

Correct Answer: 2
Rationale: The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the healthcare provider, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows.