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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.)

Transverse palmar creases

Muscular hypertonicity

Protruding tongue

Large ears

Low birth weight

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Administering oxygen via a nasal cannula is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This symptom is not indicative of hypoxia.
Choice B rationale
Having the client tuck her chin to her chest can help alleviate the tingling sensation. This position can help reduce hyperventilation, which is often the cause of the tingling.
Choice C rationale
Assisting the client to breathe into a paper bag is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This action is typically used to treat hyperventilation, but it is not the first-line intervention.
Choice D rationale
Instructing the client to increase her respiratory rate to more than 42 breaths per minute is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This could exacerbate the problem by causing further hyperventilation.

A. Observe for crowning. B. Apply fundal pressure. C. Prepare to administer oxytocin. D. Observe for the presence of a nuchal cord.

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.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. Which of the following actions should the nurse take if the client’s fingers are tingling?

Correct Answer is B

Explanation

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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