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 B
Explanation
A. The lancet should be used on the outer aspect of the heel, not the inner aspect, to avoid injury to the heel's bone and nerves. Proper technique for heel puncture is critical for successful specimen collection.
B. Warming the newborn’s heel for 5 to 10 minutes before the puncture helps to increase blood flow and ensure a sufficient blood sample for screening tests. This is a recommended practice to improve the effectiveness of the heel stick.
C. Applying an antiseptic to the heel before the puncture is correct practice, but applying it after the specimen is collected is not recommended. It can cause stinging and potentially interfere with the blood sample.
D. After the puncture, the heel should be gently massaged and then covered with a bandage to stop bleeding. Leaving the heel open to the air is not recommended as it can lead to infection or continue bleeding.
Correct Answer is C
Explanation
A. Beginning each feeding with the same breast as the previous feeding is not necessary for effective breastfeeding. It is recommended to allow the newborn to fully drain the first breast before switching to the other side to ensure they receive both foremilk and hindmilk.
B. Newborns do not need additional water. Breast milk or formula provides all the hydration and nutrients a newborn requires, and offering water can interfere with the newborn’s intake of essential nutrients and calories.
C. Allowing the newborn to empty the first breast before switching sides ensures they receive the complete range of milk, including both foremilk and hindmilk, which supports optimal growth and satisfaction.
D. Providing a formula supplement is not typically necessary unless specifically indicated for medical reasons. Exclusive breastfeeding is recommended for the first six months of life, and formula should not be introduced without cause.
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