A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select all that apply.)

Large ears

Protruding tongue

Transverse palmar creases

Muscular hypertonicity

Low birth weight

Answer and Explanation

Correct Answer : B,C

B. A protruding tongue, often due to a small mouth and poor muscle tone (hypotonia), is a common feature of Down syndrome. This tongue appearance can contribute to difficulties with feeding and speech development.

C. Instead of a single palmar crease (known as a simian crease), individuals with Down syndrome often have transverse palmar creases. This occurs in about 45-50% of cases and is considered a characteristic feature.

A. While large ears are not typically listed as a common feature, individuals with Down's Syndrome may have unusually shaped or small ears.

D. Hypertonicity refers to increased muscle tone or stiffness. In Down syndrome, however, hypotonia (reduced muscle tone) is more common, especially in infancy. Therefore, muscular hypertonicity is not typically associated with Down syndrome.

E While low birth weight can occur in some infants with Down syndrome, it is not a universal characteristic. In fact, some infants with Down syndrome may be born at average or even slightly higher birth weights.

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Correct Answer is C

Explanation

C. Monitoring respiratory rate is important because magnesium sulfate can depress respiratory function, especially if given in high doses or if the client has impaired renal function.

A. While assessing bowel sounds is important in general nursing care, it is not the priority assessment when administering magnesium sulfate.

B. Monitoring the fetal heart rate is critical when administering magnesium sulfate to a client in preterm labor. Magnesium sulfate can cross the placenta and affect the fetal heart rate and variability. However, respiratory rate is priority.

D. Monitoring temperature is important as magnesium sulfate can affect thermoregulation, potentially causing hyperthermia. However, it is not typically the most immediate concern compared to fetal heart rate monitoring when initiating magnesium sulfate therapy.

A. The newborn will be observed and treated in the neonatal intensive care unit B. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present C. A cesarean section will be necessary if vaginal lesions are present at the time of labor D. Daily administration of Valacyclovir (Valtrex) is necessary after the 36th week of pregnancy E. Total abstinence from sexual intercourse is necessary during the entire pregnancy

Correct Answer is ["B","C","D"]

Explanation

B. Sitz baths can provide comfort and help keep the affected area clean if the pregnant woman has active genital herpes lesions. This can aid in preventing secondary infection and promote healing. Therefore, this statement is appropriate advice for managing symptoms of genital herpes during pregnancy.

C. If the pregnant woman has active genital herpes lesions (particularly genital lesions or prodromal symptoms at the onset of labor), a cesarean section (C-section) is generally recommended to reduce the risk of transmission of the herpes virus to the newborn. This recommendation is based on minimizing direct contact between the newborn and the infected genital tract during delivery.

D. Valacyclovir is an antiviral medication used to suppress outbreaks of genital herpes. In pregnant women with a history of recurrent genital herpes, antiviral therapy with medications like Valacyclovir may be prescribed starting from around the 36th week of pregnancy to reduce the risk of outbreaks and shedding of the virus at the time of delivery. This is aimed at reducing the likelihood of active lesions during labor, which in turn reduces the need for a cesarean section.

A. It is not necessarily true for all cases of maternal herpes infection. Whether the newborn requires NICU observation or treatment depends on factors such as the presence of active lesions during delivery and the development of symptoms in the newborn.

E While genital herpes can be sexually transmitted, complete abstinence from sexual intercourse throughout pregnancy is not usually required unless the healthcare provider specifically advises it due to high risk or severity of the infection. However, precautions such as using condoms can significantly reduce the risk of transmitting herpes to a partner during pregnancy.

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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 preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is C

Explanation

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. What information does the nurse gives to the client?(Select All that Apply.)

Correct Answer is ["B","C","D"]

Explanation

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