The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder?

Correct Answer: D

Rationale: The correct answer is D: Hip dislocation. Asymmetry of gluteal folds in infants can indicate developmental dysplasia of the hip (DDH). The nurse should assess for other signs of hip dislocation such as limited hip abduction, leg length discrepancy, or uneven skin folds. DDH can lead to long-term issues if not treated early. A: Fractured clavicle - Unrelated to asymmetry of gluteal folds. Typically occurs during birth. B: Down syndrome - Does not typically present with asymmetry of gluteal folds. C: Spina bifida - Typically presents with neurological deficits, not asymmetry of gluteal folds.

Correct Answer: A

Rationale: The correct answer is A: Reflexes will be normal. In patients with a head injury resulting in unconsciousness without other injuries, deep tendon reflexes are expected to be normal. This is because the unconsciousness is likely due to cerebral dysfunction rather than spinal cord injury, which would affect reflexes. Choices B, C, and D are incorrect because in the absence of spinal cord injury, the deep tendon reflexes should not be affected. Choice B is incorrect as reflexes should be present and can be elicited in this scenario. Choice C is incorrect as reflexes should not be diminished unless there is spinal cord involvement. Choice D is incorrect as reflexes should not depend on the area of injury in this case.

Correct Answer: D

Rationale: The correct answer is D, Complete neurologic examination. This is because the patient's symptoms of weakness in the left arm and leg require a thorough assessment of all components of the nervous system to determine the cause accurately. A Glasgow Coma Scale (A) assesses level of consciousness, not focal weakness. A Neurologic recheck examination (B) is not appropriate as it assumes a previous neurological exam. A Screening neurologic examination (C) is too basic and may not provide enough information to diagnose the cause of the symptoms.

Correct Answer: C

Rationale: The correct answer is C: Peripheral neuropathy. In this case, the patient's inability to feel vibrations on the great toe or ankle bilaterally but being able to feel vibrations on both patellae indicates a sensory nerve dysfunction affecting distal lower extremities. This pattern of sensory loss is consistent with peripheral neuropathy, a common complication of diabetes leading to nerve damage. Hyperalgesia (choice A) is increased sensitivity to pain, which is not reflective of the patient's symptoms. Hyperesthesia (choice B) is increased sensitivity to touch, which is also not consistent with the patient's findings. Lesion of the sensory cortex (choice D) would typically present with more widespread sensory deficits rather than the specific pattern described in the question.

Correct Answer: B

Rationale: The correct answer is B because the described response is the Moro reflex, an expected startle reflex seen in infants around 7 months of age. The Moro reflex involves the abduction and flexion of the arms and legs, fanning of the fingers, and curling of the index finger and thumb in a C position, followed by bringing in the arms and legs. This reflex typically appears around birth and peaks at 2 months, then diminishes as the baby grows. It is a primitive reflex that serves as a protective response to a sudden loss of support or loud noise. Choices A, C, and D are incorrect because the response described is not indicative of brachial nerve palsy, should not have disappeared by 1-4 months, and does not need to be bilaterally symmetric to be considered normal.