The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding?

Correct Answer: A

Rationale: The correct answer is A. A positive Allis sign in an infant indicates hip dislocation. When one knee is significantly lower than the other during the Ortolani-Barlow maneuver, it suggests hip dysplasia or dislocation. This finding requires further evaluation and intervention. Choice B is incorrect because a dislocated patella does not present with this specific sign. Choice C is incorrect as a negative Allis sign is actually normal and symmetric in infants. Choice D is incorrect because immediate evaluation and management are needed for a positive Allis sign, not waiting for 2 weeks.

Correct Answer: D

Rationale: Rationale for Correct Answer (D): 1. "The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers." - This statement correctly describes the functions of afferent and efferent fibers in the peripheral nervous system. - Afferent fibers transmit sensory information from the peripheral organs to the central nervous system. - Efferent fibers transmit motor commands from the central nervous system to the peripheral organs. Summary of Incorrect Choices: A: "The CNs enter the brain through the spinal cord." - Incorrect because cranial nerves (CNs) directly connect to the brain, bypassing the spinal cord. B: "Efferent fibers carry sensory input to the central nervous system through the spinal cord." - Incorrect because efferent fibers carry motor commands away from the central nervous system, not sensory input towards it. C: "The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers

Correct Answer: A

Rationale: The correct answer is A: Reflexes. At 3 months, infants have primitive reflexes such as sucking and grasping, controlled by the brainstem and spinal cord. The nurse is assessing the infant's normal neurological development. Choice B, intelligence, is not appropriate to assess in a 3-month-old. Choice C, CNs (cranial nerves), is too specific for this assessment. Choice D, cerebral cortex function, is not fully developed at this age to control sucking and grasping.

Correct Answer: D

Rationale: The correct answer is D. Before testing the sensory system, it is crucial for the nurse to assess the patient's mental status and ability to follow directions. This is important because cognitive impairment, such as short-term memory loss and confusion, can impact the accuracy of sensory testing results. By assessing the patient's mental status first, the nurse can ensure that the sensory test results are valid and reliable. This step is essential in providing accurate and comprehensive care for the patient. A: The nurse should test the sensory system, but assessing mental status is also necessary. B: Mental status can affect sensory ability, so assessing it is crucial. C: While explaining tests is important, assessing mental status should be the priority before testing.

Correct Answer: A

Rationale: The nurse would use the Denver II test to check the motor coordination of an 11-month-old infant. This test assesses developmental milestones, including motor skills appropriate for the child's age. The Denver II test specifically evaluates gross and fine motor skills, which are crucial components of motor coordination in infants. The other choices are not appropriate for assessing motor coordination in infants. Stereognosis tests the ability to recognize objects by touch, deep tendon reflexes assess the integrity of the neuromuscular system, and rapid alternating movements evaluate cerebellar function, none of which directly measure motor coordination in infants.