A nurse is collecting data from a newborn who has fetal alcohol syndrome. Which of the following manifestations should the nurse (Select all that apply.)
Mongolian spots
Microcephaly
Single palmar crease
Thin upper lip
Small eyes
Correct Answer : B,D,E
A) Mongolian spots: Mongolian spots are common in newborns of Asian, Hispanic, and African descent and are not specifically associated with fetal alcohol syndrome (FAS). These spots are bluish-gray or purple and typically fade over time, but they are not a manifestation of FAS.
B) Microcephaly: Microcephaly, which is an abnormally small head, is a common feature of fetal alcohol syndrome. This condition results from the effects of alcohol on the developing brain during pregnancy, leading to a smaller-than-normal head size.
C) Single palmar crease: A single palmar crease is a common finding in Down syndrome and can occur in other conditions as well, but it is not a hallmark feature of fetal alcohol syndrome. While it may occasionally be seen in infants with FAS, it is not one of the most common or defining characteristics.
D) Thin upper lip: A thin upper lip is one of the hallmark facial features of fetal alcohol syndrome. It is part of the characteristic "facial dysmorphology" seen in FAS, along with other features such as a smooth philtrum
E) Small eyes: Small eyes, or microphthalmia, are also a characteristic feature of fetal alcohol syndrome. This abnormal eye size, along with other facial abnormalities, is often seen in infants affected by FAS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "I should position the car seat's retainer clip at the level of my baby's belly button.": This statement is incorrect. The retainer clip of the car seat should be positioned at the level of the baby's armpits, not the belly button. Proper placement of the retainer clip ensures the safety harness fits securely across the baby's chest, reducing the risk of injury during a crash.
B) "I should keep my baby rear-facing in the car seat until she is 2 years old.": This statement is correct and aligns with current guidelines from organizations such as the American Academy of Pediatrics (AAP). Infants and toddlers should remain in a rear-facing car seat until they are at least 2 years old or until they reach the maximum height or weight limit allowed by the car seat manufacturer for rear-facing use. Rear-facing is the safest position for infants and provides the best protection for their developing head, neck, and spine.
C) "I should enable the airbag when my baby is in the front seat of the car.": This statement is incorrect. Infants and young children should never ride in the front seat of a car with an active airbag, as airbags can cause serious injury or death in the event of a collision. Children should always be placed in the back seat, ideally in a rear-facing car seat, to minimize risk.
D) "I should place my baby in the car seat at a 90-degree angle.": This statement is incorrect. A car seat should be installed at a slight recline to ensure that the baby's airway remains open and to prevent their head from falling forward. A 45-degree angle is typically recommended for newborns, although this can vary based on the specific car seat model and the baby's size.
Correct Answer is D
Explanation
A) Wear sterile gloves to remove the dressing: For a wet-to-dry dressing change, clean gloves are typically used when removing the dressing, as the procedure does not require a sterile technique unless the wound is being directly cleaned or treated with sterile instruments. Wearing sterile gloves for removal is unnecessary and could increase the risk of contamination when handling non-sterile dressing material.
B) Remove the tape by pulling from the center of the dressing: Tape should be removed by pulling it gently from the edges rather than from the center. Pulling from the center may cause unnecessary trauma to the surrounding skin or disrupt the wound's healing process. Gently pulling from the edges helps reduce the risk of skin irritation and minimizes discomfort for the patient.
C) Moisten dressing before removal: The dressing should be moistened before application, not before removal. Wetting the dressing before removing it may actually cause further trauma to the wound, and it might be difficult to remove the wet-to-dry dressing cleanly. The dressing should be removed first, and then a new dressing should be moistened if needed.
D) Clean the wound from the center to the outer edges: When cleaning a wound, the nurse should always clean from the center of the wound to the outer edges in a circular motion. This helps prevent the spread of bacteria from the outer contaminated areas into the clean tissue. By cleaning from the center outward, the nurse reduces the risk of introducing new bacteria into the wound site.
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