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) "A child who has leukemia and an absolute neutrophil count of 200/mm³ (2,500 to 8,000/mm³)."
This child is at significant risk for infection due to a severely low neutrophil count, indicating severe neutropenia. Discharge planning for this child would be inappropriate at this time since they need intensive monitoring and care to manage their immunocompromised status and prevent infections.
B) "A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin."
This child is appropriate for discharge planning. A new diagnosis of type 1 diabetes requires thorough teaching for the family and child about blood glucose monitoring, insulin administration, dietary adjustments, and emergency management. While the child is receiving IV insulin in the hospital, once stabilized, they can be discharged with proper education and support to manage their condition at home.
C) "An adolescent who has cystic fibrosis and is receiving their yearly tune-up."
A cystic fibrosis "tune-up" refers to a period of treatment, often including IV antibiotics and respiratory therapy, to help manage the chronic condition. Since this is part of ongoing care and not an acute issue, discharge planning is not immediately appropriate until the "tune-up" is complete, and the adolescent has stabilized.
D) "An infant who has respiratory syncytial virus (RSV) and a respiratory rate of 70/min."
This infant is at risk for respiratory distress and requires close monitoring. A respiratory rate of 70/min in an infant is elevated, and the child may need additional respiratory support. Discharge planning should not be initiated until the infant's condition improves and they are stable enough to handle care at home.
Correct Answer is B
Explanation
A) Medical health insurance claims:
Medical health insurance claims are not relevant to the referral for physical therapy. This information is typically handled by billing departments and insurance providers. The focus of a physical therapy referral is on the patient's clinical condition and needs, not their insurance coverage.
B) Physical assessment findings:
This is the most relevant information to include in a referral for physical therapy. The physical assessment findings provide the physical therapist with important details about the client's mobility, strength, range of motion, and other factors that can guide the creation of an individualized therapy plan. These findings help the therapist understand the client's current physical capabilities and limitations.
C) Medications taken prior to admission:
While it is important for the healthcare team to be aware of the medications a client is taking, this information is not as crucial for the physical therapy referral itself. The physical therapist may need to know about medications if they have a direct impact on the client's physical functioning (e.g., sedatives or pain medications), but the primary focus for the referral would be on the physical assessment findings.
D) Family medical history:
Family medical history is typically relevant to a broader health assessment but is not generally included in a referral for physical therapy. The therapist will be more concerned with the client's current physical condition and functional abilities rather than the medical history of the client's family.
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