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

Hypertonia

Large ears

Transverse palmar creases

Protruding tongue

Low birth weight

Answer and Explanation

Correct Answer : C,D

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.

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Correct Answer is C

Explanation

A. Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.

A. Call the child abuse hotline B. Educate the mother on safety C. Inform the mother to call the nurse for all diaper changes D. Complete the Morse Fall Scale

Correct Answer is A

Explanation

A. Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale. This is irrelevant in the context of suspected child abuse.

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

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Naxlex Comprehensive Predictor Exams

When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

Correct Answer is C

Explanation

A newborn is admitted with a diagnosis of a spiral fracture of the right femur. The mother states the child received the injury when the baby fell off the changing table. Which would be the priority nursing intervention?

Correct Answer is A

Explanation

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