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. The deltoid muscle is not recommended for newborns; the vastus lateralis is the preferred site for intramuscular injections.
B. A 25-gauge needle is an appropriate size for newborn injections, but needle choice alone is not the priority action for this specific medication administration.
C. Phytonadione (Vitamin K) is typically administered within the first 6 to 12 hours after birth, allowing time for initial stabilization and bonding before injection, while still preventing vitamin K deficiency bleeding.
D. The mother’s Rh factor is unrelated to vitamin K administration; it is only assessed when considering the need for Rho(D) immune globulin.

A. Blurred vision B. Shortness of breath C. Non-pitting ankle edema D. Leukorrhea

Correct Answer is A

Explanation

A. Blurred vision can indicate a prenatal complication, such as preeclampsia, which is a serious condition that can develop in the later stages of pregnancy and requires immediate attention. Preeclampsia can lead to severe health issues for both the mother and baby.
B. Shortness of breath can be a normal part of late pregnancy due to the pressure on the diaphragm from the growing uterus. While it should be monitored, it is not specifically indicative of a complication compared to other symptoms.
C. Non-pitting ankle edema is common in the later stages of pregnancy and is not necessarily a sign of a complication on its own. It can occur due to the increased fluid volume and pressure from the uterus.
D. Leukorrhea, or increased vaginal discharge, is a common and normal finding in pregnancy, especially as labor approaches. It is generally not a sign of a complication unless accompanied by other concerning symptoms.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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