The nurse is examining a 3-month-old infant. While the nurse holds his or her thumbs on the infant's inner mid thighs and the fingers on the outside of the infant's hips, touching the greater trochanter, the nurse adducts the legs until the his or her thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds. How should the nurse document this finding?

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This maneuver is the Ortolani sign. Normally this maneuver feels smooth and has no sound (negative Ortolani sign). However, with a positive Ortolani sign the nurse will feel and hear a "clunk," as the head of the femur pops back into place. A positive Ortolani sign also reflects hip instability. The Allis test also tests for hip dislocation but is performed by comparing leg lengths. The Allis test is a test that assesses for hip dislocation but comparing leg lengths. The maneuver described in this question is the Ortolani sign. Normally this maneuver feels smooth and has no sound (negative Ortolani sign). However, with a positive Ortolani sign the nurse will feel and hear a "clunk," as the head of the femur pops back into place. A positive Ortolani sign also reflects hip instability.

The Nurse Is Examining a 3-Month-Old Infant