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.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Early decelerations in the fetal heart rate (FHR) are caused by compression of the fetus’s head during a uterine contraction. This often happens during later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position. This causes the uterus to squeeze the head during contractions.
Choice B rationale
Uteroplacental insufficiency is a condition where the placenta does not provide enough oxygen and nutrients to the fetus. This condition is typically associated with late decelerations in the FHR, not early decelerations.
Choice C rationale
Altered fetal cerebral blood flow is not typically associated with early decelerations in the FHR34.
Choice D rationale
Umbilical cord compression is typically associated with variable decelerations in the FHR, not early decelerations.
Correct Answer is A
Explanation
Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
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