A nurse is assessing a newborn who has Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.)
Transverse palmar creases
Muscular hypertonicity
Protruding tongue
Large ears
Low birth weight
Correct Answer : A,C
The correct answers are A. Transverse palmar creases and C. Protruding tongue.
Choice A rationale:
Transverse palmar creases, also known as a single palmar crease, are a common characteristic of Down syndrome. This feature is present in many individuals with the condition.
Choice B rationale:
Muscular hypertonicity (increased muscle tone) is not typical in Down syndrome. Instead, individuals with Down syndrome often have hypotonia (decreased muscle tone).
Choice C rationale:
A protruding tongue is a common characteristic of Down syndrome. This is due to a combination of factors, including a small oral cavity and low muscle tone.
Choice D rationale:
Large ears are not a typical feature of Down syndrome. Individuals with Down syndrome often have small or unusually shaped ears.
Choice E rationale:
Low birth weight is not specifically associated with Down syndrome. While some infants with Down syndrome may have low birth weight, it is not a defining characteristic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assisting with amnioinfusion is not the first priority. Amnioinfusion is a procedure where a sterile solution is introduced into the uterus to increase the volume of fluid around the fetus. It is typically used in cases of oligohydramnios (low amniotic fluid) or to dilute thick meconium in the amniotic fluid.
Choice B rationale
Inserting a scalp electrode is not the first priority. A scalp electrode is a device used to monitor the fetal heart rate more accurately. It is usually used when external monitoring does not provide a clear reading or when there is a need for continuous detailed monitoring.
Choice C rationale
Changing the woman’s position is the correct action. Late decelerations in the fetal heart rate can be a sign of uteroplacental insufficiency, a condition where the placenta cannot deliver adequate oxygen to the fetus. Changing the woman’s position can improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Notifying the health care provider is important but not the first priority. The nurse should first attempt interventions such as changing the woman’s position to improve the fetal heart rate.
Correct Answer is A
Explanation
Choice A rationale
The priority action by the nurse following an amniotomy is to assess the fetal heart rate. This is because changes in the fetal heart rate can indicate fetal distress, which could be caused by cord compression or other complications related to the amniotomy.
Choice B rationale
While assessing the odor of the amniotic fluid is important to identify possible infections, it is not the priority action following an amniotomy.
Choice C rationale
Providing clean, dry underpads is part of standard care following an amniotomy, but it is not the priority action.
Choice D rationale
Monitoring the client’s temperature is important to identify possible infection, but it is not the priority action immediately following an amniotomy.
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