A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?

Sunken fontanels

Retinal hemorrhage

Laceration to forearm.

Large bruises on the body

Answer and Explanation

The Correct Answer is B

A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.

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Correct Answer is ["C","D"]

Explanation

Answer: C, D

A. Hypertonia
Hypertonia, or increased muscle tone, is not a common characteristic of Trisomy 21. In fact, many infants with Down's Syndrome typically exhibit hypotonia, or decreased muscle tone, which can affect their overall strength and development.

B. Large ears
While individuals with Down's Syndrome may have unique ear shapes, "large ears" are not specifically characteristic of Trisomy 21. Instead, the ears may appear small or have a different shape compared to those of typically developing children.

C. Transverse palmar creases
Transverse palmar creases, also known as simian lines, are commonly seen in individuals with Down's Syndrome. This feature is a characteristic finding that can help in identifying the condition during physical assessment.

D. Protruding tongue
A protruding tongue is a common feature in individuals with Down's Syndrome. This occurs due to hypotonia of the oral muscles, which can lead to difficulties in tongue control and positioning.

E. Low birth weight
Low birth weight is not a defining characteristic of Trisomy 21. In fact, newborns with Down's Syndrome can have varying birth weights; they are often average weight or slightly above average, although some may be below average due to other factors related to maternal health or gestational issues.

A. Sole creases on heels B. Ruddy skin color C. Flexion of all four (4) extremities D. Scant amount of vernix caseosa

Correct Answer is D

Explanation

A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.

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A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select All that Apply.)

Correct Answer is ["C","D"]

Explanation

The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?

Correct Answer is D

Explanation

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