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 A
Explanation
Choice A rationale
When the fetal head is at 3+ station, it means that the baby’s head has moved down the birth canal and is very close to the vaginal opening. At this stage, the nurse should observe for crowning, which is when the widest part of the baby’s head can be seen at the vaginal opening. This is a critical time during labor, and the nurse needs to be prepared for the delivery of the baby.
Choice B rationale
Applying fundal pressure is not recommended as it can cause complications such as uterine rupture, fetal distress, and maternal discomfort. It is also not necessary when the fetal head is at 3+ station as the baby is already moving down the birth canal.
Choice C rationale
Oxytocin is a hormone that can stimulate uterine contractions. However, it is not necessary to prepare to administer oxytocin when the fetal head is at 3+ station. At this stage, the mother’s body is already effectively progressing through labor.
Choice D rationale
Observing for the presence of a nuchal cord, which is when the umbilical cord is wrapped around the baby’s neck, is important throughout labor. However, it is not the primary action the nurse should take when the fetal head is at 3+ station.
Correct Answer is A
Explanation
Choice A rationale
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
Choice B rationale
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
Choice C rationale
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Choice D rationale
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.
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