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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Using a plastic cover on the crib mattress is not recommended because it can increase the risk of suffocation or overheating. Crib mattresses should be kept clean, but protective covers are not recommended for safety.
B. Placing a foam-wedge cushion under the newborn during naps is unsafe and increases the risk of Sudden Infant Death Syndrome (SIDS). Newborns should be placed on a firm, flat mattress for all sleep periods.
C. Ensuring that the mattress fits securely against the sides of the crib is crucial for preventing suffocation hazards. A snug fit between the mattress and crib sides prevents entrapment and ensures the baby’s safety while sleeping.
D. Placing bumper pads between the mattress and the rails of the crib is considered dangerous as they can pose suffocation and strangulation risks. Bumper pads are not recommended due to these safety hazards.

A. "Assist the client's partner to apply counterpressure to the sacrum." B. "Teach the client to hold their breath during contractions." C. "Maintain the client on bed rest until active labor begins." D. "Insert an indwelling urinary catheter."

Correct Answer is A

Explanation

A. Counterpressure applied to the sacrum is effective for relieving low-back pain during labor. This technique can help alleviate discomfort associated with contractions and provide comfort to the laboring client.
B. Holding the breath during contractions is not recommended as it can decrease oxygen flow to the mother and baby. Breathing techniques that focus on relaxation and proper oxygenation are preferred.
C. Bed rest is not necessary for a client in early labor and can be counterproductive. Allowing the client to move and find comfortable positions is more beneficial during early labor.
D. An indwelling urinary catheter is not required in early labor unless there is a specific medical reason. Routine catheterization is not a standard part of early labor management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about crib safety with a group of prenatal clients. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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