A nurse in the newborn nursery is caring for an infant who has trisomy 21. When collecting data, which of the following findings should the nurse expect?
A single crease in the palm
A notch in the lip
Extra digits on the hand
An inversion of the foot
The Correct Answer is A
A. A single crease in the palm is correct. A single transverse palmar crease (simian line) is a common finding in infants with trisomy 21.
B. A notch in the lip is not a common finding in trisomy 21. This feature is more associated with other conditions like cleft lip or palate.
C. Extra digits on the hand (polydactyly) is not characteristic of trisomy 21. It is more commonly associated with other genetic conditions.
D. An inversion of the foot (clubfoot) is not a specific finding for trisomy 21. While some infants with trisomy 21 might have foot deformities, this is not a defining characteristic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Douching is not recommended as it can disrupt the natural vaginal flora and potentially lead to further infections. Instead, maintaining good hygiene without douching is advised.
B. Urinating before bedtime is actually recommended to help flush out bacteria from the urinary tract. Avoiding urination at bedtime can increase the risk of developing a urinary tract infection.
C. Bubble baths can irritate the vaginal area and increase the risk of a urinary tract infection. Pregnant clients should be advised to avoid bubble baths and use mild, unscented soaps instead.
D. Yogurt products are beneficial because they contain probiotics that can help maintain a healthy balance of bacteria in the vagina and urinary tract. Eliminating yogurt from the diet is not necessary and may be counterproductive.
E. Wearing cotton-crotch underwear helps keep the vaginal area dry and reduces the risk of infections. Cotton allows for better air circulation and absorbs moisture compared to synthetic fabrics.
Correct Answer is C
Explanation
A. Blood pressure 156/80 mm Hg is incorrect. While this blood pressure reading is elevated, hypertension is not a typical immediate sign of postpartum hemorrhage. Hemorrhage is more commonly associated with hypotension (low blood pressure) due to fluid loss.
B. Temperature 38.3° C (101° F) is incorrect. A mild fever may be common in the first 24 hours postpartum due to normal inflammatory responses. It is not specifically indicative of postpartum hemorrhage, though a persistent fever could indicate an infection.
C. Respiratory rate 32/min is correct. An increased respiratory rate can be a sign of hypovolemia (due to significant blood loss), which may occur with postpartum hemorrhage. The body compensates for decreased blood volume by increasing the respiratory rate.
D. Apical pulse 66/min is incorrect. A heart rate of 66/min is within normal limits and would not be indicative of postpartum hemorrhage. In fact, a tachycardic (elevated) heart rate is more concerning in the case of hemorrhage as the body tries to compensate for blood loss.
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